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HYSTERICAL    ELEMENT /^^ 


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Orthopedic   Surgery 


B  Y 


NEWTON  M.  SHAFFER,  M.  D., 

SURGEON  IN  CHARGE  OF  THE   NEW    YORK    ORTHOPEDIC   DISPENSARY    AND    HOS- 
PITAL,   ORTHOP/EDIC    SURGEON  TO    ST.  LUKE'S   HOSPITAL,  N.   Y. 


NEW  YORK 
G.    P.    PUTNAM'S     SONS 

182  Fifth  Avenue 
1880 


-^tA 


Copyright  by 

G.  P.  PUTNAM'S  SONS 

1880 


Press  0/ 

G.    P.   Piitnatn's   Sorts 

i8a  I'i/th  Ai'enue 

New  York 


PREFACE. 


THIS  essay  was  read  before  the  New  York  Neurological 
Society  on  December  i,  1879,  and  was  published  in  three 
consecutive  numbers  of  the  Archives  of  Medicine.  The  import- 
ance of  the  subject  considered  and  its  almost  entire  neglect  by 
writers  on  Orthopsedic  Surgery,  are,  it  is  considered,  sufficient 
reasons  for  submitting  it  to  the  profession  in  its  present  form. 

Several  foot-notes  and  remarks  have  been  added  to  the  original 
manuscript,  and  every  effort,  compatible  with  the  scope  of  a  So- 
ciety paper  and  the  space  allotted  to  it  in  the  Archives,  has  been 
made  to  render  the  subject  matter  of  value  to  the  general  prac- 
titioner. 

NEWTON  M.  SHAFFER. 

No.  31  West  36TH  St.,  New  York, 
April  i,   1880. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/hystericalelemenOOshaf 


CONTENTS 


PAGE 

Introductory  Remarks            .....'....  I 

Nervous  Mimicry  of  Knee  Joint  Disease  ......  7 

Cases,  Comments  and  Treatment           .......  7-14 

Differential  Table  of  the  Symptoms  of  Chronic  Synovitis  and  Chronic 

Osteitis  of  the  Knee  Joint           .......  17 

Remarks  on  the  differential   diagnosis   of    true   and  false  Knee  Joint 

Lesions       ...........  18-21 

Nervous  Mimicry  of  Hip  Joint  Disease      ......  22 

Cases,  Comments  and  Treatment           .         .          .         .          .          .          .  22-34 

Remarks    on    the  differential    diagnosis   of  true    and   false    Hip   Joint 

Disease      ...........  34-36 

Nervous  Mimicry  of  Pott's  Disease    .......  39 

Cases,  Comments  and  Treatment           .......  39-43 

Remarks  on  differential  diagnosis  of  true  and  false  Pott's  Disease     .  43-45 

Nervous  Mimicry  of  Lateral  Curvature  of  the  Spine      ....  45 

Hypothetical  Case  and  Comments     .......  49-51 

Remarks  on  differential  diagnosis  of  true  and  false  Lateral  Curvature    .  46-49 

Remarks  on  Treatment      .........  52 

Reference  to  the  simulated  lesions  of  other  articulations          ...  53 

Hysterical  Club  Foot         .........  53 

Cases,  Comments  and  Treatment           .......  54-62 

Remarks  on  the  use  of   the  Faradic  Current   as   a   means   of  diagnosis  62 

Conclusions           ...........  65-66 


THE  HYSTERICAL  ELEMENT  IN  ORTHOPEDIC 
SURGERY* 

By   NEWTON  M.    SHAFFER,  M.D. 

SURGEON  IN  CHARGE    OF    THK   NEW  YORK   ORTHOPEDIC   DISPENSARY. — ORTHO- 
PAEDIC SURGEON  TO  ST.   LUKe'S  HOSPITAL. 

THERE  are  two  important  systems  involved  in  the 
process  of  acute  local  inflammation,  namely,  the 
vascular  and  the  nervous.  The  pathological  changes  wrought 
through  the  operations  of  the  one  and  the  contributive 
influence  of  the  other  in  forming  the  group  of  symptoms 
which  characterize  this  condition,  need  no  comment.  A 
typical,  local,  acute  inflammation  cannot  easily  be  mistaken 
for  any  other  pathological  state.  As  we  descend  in  the 
scale  and  pass  to  a  study  of  the  sub-acute  local  lesions,  we 
find  that  the  dif^culties  in  the  way  of  diagnosing  this  con- 
dition are  not  materially  increased.  But  in  the  first  stage 
of  certain  chronic  diseases  we  lose  many  of  the  symptoms 
by  which  the  local,  as  well  as  the  general,  evidences  of 
inflammation  are  recognized  and,  aside  from  the  length 
of  time  which  the  history  of  the  case  may  have  covered, 
there  are,  not  infrequently,  confusing  elements  introduced 
into  the  etiological  and  semeiological  factors  which  de- 
mand more  attention,  I  think,  than  has  been  accorded  to 
them  by  some  of  our  most  eminent  teachers. 

*  Read  before  the  New  York  Neurological  Society,  December  ist,  1879. 


2  NEWTON  M.   SHAFFER. 

It  would  seem  that  the  symptoms  that  arise  from  path- 
ological changes,  which,  whatever  be  their  etiology,  affect 
principally  the  local,  vascular  tissues  of  a  part  could  be 
easily  distinguished  from  those  which  find  expression 
through  the  medium  of  the  peripheral  nerves  alone.  And, 
so  far  as  the  acute  local  lesions  are  concerned  there  should 
be  no  difficulty.  But  many  chronic  diseases  do  not  present, 
especially  in  the  first  stage,  symptoms  of  any  urgency 
whatever;  they  are  not  accompanied  by  any  constitutional 
disturbance  and  the  insidious  progress  of  the  disease  is  very 
suggestive  of  the  manner  in  which  the  lesion  is  undermining 
the  tissues  involved.  In  the  acute  local  lesion,  the  vascular 
plays  the  important  part,  and  attention  is  chiefly  directed  to 
it,  both  as  regards  symptoms  and  treatment.  On  the  other 
hand,  in  some  forms  of  chronic  inflammation,  and  especially 
in  certain  lesions  of  the  articulations,  the  neural  element 
predominates  and  the  vascular  symptoms  are,  in  many 
cases,  not  at  all  apparent.  These  facts  being  duly  recog- 
nized, it  becomes  clear  why  so  many  of  the  so-called  hys- 
terical, surgical  cases  resemble  an  insidiously  progressive 
chronic  disease  ;  for  with  chronic  inflammation  there  is  al- 
ways a  localized  disturbance  of  function,  associated  with 
other  symptoms  which  in  many  instances  are  very  obscure 
and  of  uncertain  etiology,  while  in  the  hysterical  state  there 
is  also  localized  disturbance  of  function  associated  with 
manifestations  which  possess,  in  many  instances,  all  the 
important  characteristics  of  local  inflammation. 

For  many  years  the  effect  of  the  emotions,  not  only  in 
producing,  but  also  in  relieving  abnormal  states,  has  been 
recognized.  In  Burton's  "Anatomy  of  Melancholy"  may 
be  found  references  to  the  value  of  this  factor  both  in  diag- 
nosis and  treatment.  Many  other  works  could  be  referred 
to,  illustrating  this  point,  with  interest  and  profit.  But  this 
is  scarcely  the  occasion   for  an   extended  research  into  the 


HYSTERICAL  JOINT  AFFECTIONS.  3 

literature  of  this  subject.  Nor  will  it  be  of  service  to 
attempt  an  analysis  of  the  relations  of  the  three  great 
nervous  centres  to  the  phenomena  which  are  generally  de- 
scribed as  hysterical.  We  would  rather  say  with  Dr.  Rey- 
nolds that  "  the  essential  fact  of  Hysteria  is  in  the  dis- 
turbed balance  between  the  voluntary  and  involuntary 
power.  Volition  is  defective ;  emotional,  sensational  and 
reflex  activity  are  in  excess,  and  the  distortion  may  be 
brought  about  by  the  many  divers  circumstances  of  age, 
sex,  position,  employment, — but  the  precise  nature  of  the 
change  which  is  the  ef^cient  cause  of  such  distortion,  i.e., 
the  primary  physical  fact  in  the  pathology  of  Hysteria,  has 
yet  to  be  discovered.*  " 

Tuke  remarks  :  "  We  have  seen  that  the  influence  of  the 
mind  upon  the  body  is  no  transient  power  ;  that  in  health 
it  may  exalt  the  sensory  functions,  or  suspend  them  alto- 
gether ;  excite  the  nervous  system  so  as  to  cause  the  vari- 
ous forms  of  convulsive  action  of  the  voluntary  muscles,  or 
depress  it  so  as  to  render  them  powerless  ;  may  stimulate  or 
paralyze  the  muscles  of  organic  life,  and  the  processes  of 
nutrition  and  secretion  ; — causing  even  death. f  " 

It  will  not  be  dif^cult  for  us,  therefore,  to  appreciate  the 
effect  of  emotional  activity  upon  the  voluntary  muscles. 
Indeed,  all  the  sensations  of  which  these  muscles  are  capa- 
ble, all  the  movements  they  may  be  made  to  undergo  in 
response  to  the  will,  may  be  excited  by  this  emotional 
cause,  or  voluntary  muscular  action  may  be  apparently 
wholly  lost  through  the  same  disturbing  element.  Still 
more,  the  various  morbid  sensations  of  the  surface  may 
be  produced.  Even  superficial  vascular  changes  may  be 
brought  about,  inducing  a  local  hyperaemia  or  an  ischaemia. 
With  defective  volition,   an  excess  of  emotion,   undue   ac- 

*  A  System  of  Medicine,  edited  by  J.  Russell  Reynolds,  M.I3.,  vol.  ii,  p.  loi. 
f  Influence  of  the  Mind  upon  the  Body,  by  Daniel  Hack  Tuke,  M.  D.,  M.  R. 
C.  P.     p.  395- 


4  NE  IV TON  M.   SHAFFER. 

tivity  of  sensation,  and  an  easily  excited  reflex  move- 
ment— especially  if  complicated  by  precocity  in  the  child, 
or  mental  exhaustion  in  the  adult,  a  long  and  intricate 
series  of  symptoms  may  follow,  including  disturbed  mus 
cular  action,  varying  from  the  most  extensive  and  general 
convulsion  to  the  semi-tetanized  muscles  of  one  of  the 
extremities,  and  from  an  apparent  hemiplegia  to  the  loss  of 
power  over  a  group  of  flexors.  If  these  facts  be  appre- 
ciated, we  can  wholly  coincide  with  Tuke  when  he  says 
that  "  there  is  no  sensation,  whether  general  or  special, 
excited  by  agents  acting  upon  the  body  from  without, 
which  cannot  be  excited  also  from  within  by  emotional 
states."  *  And  to  this  statement  we  may  add :  There 
is  no  articular  deformity  depending  upon  chronic  inflam- 
mation or  disturbed  muscular  action — be  it  either  loss  of 
power  or  contraction — which  cannot  be  simulated,  and  not 
unfrequently  is  simulated  in  the  conditions  which  I  have 
briefly  attempted  to  describe. 

The  early  writers  on  diseases  of  the  joints  fail  to  mention 
the  existence  of  that  variety  of  articular  deformity  which  is 
associated  with  a  more  or  less  marked  h}'sterical  diathesis. 
Since  the  time,  however,  that  Brodie  called  attention  to 
the  circumstance  that  many  serious  pathological  conditions 
might  be  closely  simulated  by  the  condition  which  Skeyf 
recognises  but  does  not  name,  except  to  call  it  Hysteria, 
which  Paget  \  more  recently  describes  as  Neuromimesis, 
and  which  Esmarch  §  calls  Gclcnkncnrosc,  the  fact  that 
these  peculiar  disturbances  of  the  nervous  system  may 
successfully  imitate  the  more  serious  deformities  has  been 
recognized  ;  though,  strange  as  it  may  seem,  some  of  the 
more  recent  and   pretentious   works  on  the  subject  of  joint 

*  Op.  cit.   page  146. 

\  Lectures  on  Hysteria,  New  York,  1867. 

:|:  Clinical  Lectures  and  Essays,  New  York,  1875. 

§  Ueber  Gelcnkneurosen,  Kiel,  1872. 


H  YS  T ERICA  L  JOIN  T  A  FFE  C  TIONS.  5 

disease  and  club  foot  do  not  even  refer  to  the  fact  that  there 
are  such  conditions  as  hysterical  deformities,  while  others 
dismiss  the  matter  with  only  a  passing  notice. 

In  very  many  important  respects  the  false  so  closely  re- 
sembles the  real  disease  that  even  the  most  experienced  are, 
at  times,  at  loss  to  decide  whether,  for  instance,  a  given  ar- 
ticulation is  in  a  condition  of  progressive  chronic  disease, 
or  simply  in  a  neuromimetic  state.  Esmarch,  after  calling 
attention  to  the  difficulties  in  diagnosis,  relates  that  for 
many  weeks  he  was  undecided  regarding  the  state  of  an 
ankle  joint,  which  ultimately  proved  to  be  in  a  condition 
of  caries  sicca,  and  required  amputation.  Skey's  testi- 
mony on  this  point  is  forcibly  stated  as  follows:  "  It  may 
be  asserted  with  truth  that  every  part  of  the  human  body 
supplied  with  nerves — be  they  cerebral,  spinal  or  ganglionic 
— may  become,  under  provocation,  the  seat  of  local  symp- 
toms so  closely  resembling  the  real  disease  to  which  that 
part  of  the  body  is  liable,  as  to  appear  identical  with  it, 
and  the  resemblance  to  which  is  so  perfect  as  to  deceive  the 
best  of  us."  Paget  says,  after  enumerating  some  of  the  hys- 
terical conditions: — "And  there  is  scarcely  any  of  these 
disorders  in  which  the  mimicry  of  real  disease  is  not  some- 
times so  close  as  to  make  the  diagnosis  very  difificult." 

If  these  cases  were  rare  they  would  be  regarded  as  singu- 
lar phemomena,  but  their  frequency  takes  them  from  the  list 
of  even  infrequent  maladies  and  calls  for  recognition  from 
all,  since  each  one  of  us  is  apt  to  meet  them  any  day.  Brodie 
makes  this  remarkable  assertion — which  Esmarch  fully  en- 
dorses :  "  I  do  not  hesitate  to  declare  that  among  the  higher 
classes  of  society  at  least  four-fifths  of  the  female  patients 
who  are  commonly  supposed  to  labor  under  disease  of  the 
joints,  labor  under  hysteria  and  nothing  else."  Skey,  who 
obtained  much  of  his  knowledge  of  hysteria  in  St.  Bartholo- 
mew's Hospital,  "  includes  a  large  proportion  of  the  lower 


6  NE  WTON  M.   SHAFFER. 

classes,"  and  says,  "  in  reference  to  spinal  affections  in 
young  persons  I  unhesitatingly  assert  that  the  real  disease 
is  not  found  in  a  greater  proportion  than  one  case  in  twenty 
— and  even  this  is  a  liberal  allotment." 

My  own  experience  convinces  me  that  neuromimetic  joints 
and  spines,  and  more  particularly  the  latter,  are  very  fre- 
quent both  in  the  upper  and  lower  classes,  and  especially  at 
that  age  when  hysteria  is  most  likely  to  develop.  In  other 
words,  I  may  say  that  many  cases  of  simulated  disease  of 
the  articulations  are  not  recognized  as  such,  and  it  is  a 
fair  presumption  that  some,  perhaps  many,  of  the  remark- 
able "  cures  "  of  which  we  hear  now  and  then  have  been 
cases  which,  while  presenting  all  or,  at  least,  the  more  sug- 
gestive symptoms  of  the  lesion,  were  simply  in  a  state  of 
neuromimesis.  And  this  statement  is  notably  true  of  the 
class  of  charlatans  who  profess  to  have,  by  inheritance  or 
otherwise,  the  ability  to  cure  these  diseases  by  processes 
peculiar  to  themselves. 

The  cause  of  these  erratic  manifestations  of  the  nervous 
system  is  very  obscure.  That  it  is  not  "  mimicry"  in  the 
literal  sense  of  the  word  is  proven  by  the  fact  that  the  ma- 
jority of  my  own  cases  have  never  had  the  opportunity  to 
become  acquainted  with  the  symptoms  of  the  disease  itself. 
The  causes  assigned  by  the  patients  have  been  those  which 
are  ordinarily  looked  for  in  a  history  of  chronic  joint  disease. 
A  fall,  a  sprain,  or  over-exercise  in  skating  or  walking,  in 
the  majority  of  cases,  forms  the  occasion  for  the  first  mani- 
festation of  the  symptoms,  though,  as  in  the  real  disease,  a 
history  of  traumatism  is  often  wanting.  After  the  symp- 
toms once  find  a  local  expression,  they  partake  of  all  the 
pertinacity  and  chronicity  of  joint  diseases,  and  whether  the 
muscular  disturbances  partake  of  the  character  of  an  inter- 
mittent contraction,  or  of  the  typical  hysterical  contracture ; 
whether  the  general  nervous  symptoms  are  partly  held  in 


HYSTERICAL  JOINT  AFFECTIONS.  7 

subjection  by  will  power  alone,  or  give  evidence  of  func- 
tional disturbance  by  various  erratic,  emotional  or  typical 
hysterical  symptoms,  the  solution  of  the  enigma  lies  in  a  fa- 
miliarty  with  the  natural  history  and  course  of  the  real  dis- 
ease. 

I  have  deemed  it  best  in  presenting  a  few  of  the  cases  I 
have  met  with,  to  follow  the  regional  method,  to  bring  out 
as  fully  as  possible  the  symptoms,  and  to  compare  them 
with  those  of  the  chronic  lesions  of  the  joint  involved.  In 
following  this  plan  I  propose  to  give  a  full  history  of  each 
case, — fuller,  perhaps  in  some  instances,  than  some  might 
think  necessary;  but  as  many  of  the  differential  points  are 
interwoven  with  the  manner  in  which  the  history  was  de- 
veloped, I  have  thought  it  proper  to  give  a  few  of  the  his- 
tories practically  unabridged.  As  the  knee  joint  affords 
an  excellent  opportunity  to  study  both  the  real  and  sim- 
ulated states,  I  will  present  some  cases  of  neuromimesis  of 
this  articulations  first.  We  will  then  consider  the  hip  and 
spine,  and  lastly,  club  foot, — giving  comments,  differential 
tables   and   conclusions  in  their  proper   places. 

Case  i. — While  on  a  visit  to  Troy,  N.  Y.,  in  December,  1876, 
I  was  asked  by  my  friend.  Dr.  W.  P.  Seymour,  to  see  with  him 
a  little  girl  of  5  years  of  age,  the  daiigliter  of  a  clergyman  living 
near  the  city,  who  had  been  troubled  with  some  very  suggestive 
symptoms  affecting  the  hip  and  knee  joints  on  the  left  side — 
following  a  fall — and  which  had  existed  for  several  weeks.  I 
was  introduced  to  the  patient  at  dinner,  and  had  the  opportunity 
of  watching  her  as  she  sat  at  the  table.  She  was  evidently  a  pre- 
cocious child,  and  mentally  very  active.  She  had  that  peculiar 
complexion  which  is  supposed  to  be  indicative  of  the  strumous 
habit.  I  also  noted  that  she  had  large  eyes,  with  long  eyelashes, 
blueish  sclerotic,  pale  skin,  showing  the  temporal  veins  very 
clearly,  and  a  luxuriant  growth  of  hair.  These  facts,  with  the 
characteristic  gtit  and  attitude  of  chronic  joint  disease,  which 
were  noted  as  she  left  the  table,  led  me  to  infer  that  our  patient 
had  some  serious  chronic  inflammation  of  either  the  hip  or  knee. 


is  NEWTON  M.   SHAFFER. 

Indeed,  a  diagnosis  of  morbus  coxarius  had  already  been  made 
by  a  prominent  surgeon  of  Albany,  who  had  examined  the  case 
a  few  days  prior  to  my  visit  ;  a  diagnosis,  however,  which  Dr. 
Seymour  had  rejected.  After  dinner  a  critical  examination  of 
the  patient  was  made.  In  the  standing  position  there  was  at  once 
apparent  a  slight  discoloration  of  the  tissues  over  the  knee  joint, 
a  marked  flexion  of  the  articulation  (about  35°),  and  a  perceptible 
atrophy  of  the  thigh  and  leg.  The  patient  stood  in  the  attitude 
characteristic  of  hip  disease,  with  exagerated  flexion  at  the  knee. 
Almost  the  entire  weight  of  the  body  fell  upon  the  unaft'ected 
limb,  and  there  were  evident  the  lowered  gluteo  femoral  crease, 
the  flattened  natis  and  the  tilting  downward  of  the  pelvis  on  the 
affected  side,  which  makes  the  limb  seem  apparently  longer,  and 
produces  the  symptomatic  lateral  curvature  of  chronic  coxitis. 
When  asked  to  bend  forward  to  pick  up  a  key  from  tlie  floor, 
the  patient  carried  the  entire  limb,  in  its  deformed  position,  back- 
ward with  the  pelvis,  refusing  to  bend  in  the  slightest  degree 
either  the  hip  or  knee.  When  the  patient  walked,  little  or  no 
motion  was  apparent  at  the  hip  joint,  the  knee  was  neither  flexed 
nor  extended,  and  the  limp  was  very  marked  and  characteristic  of 
chronic  osteitis  of  the  hip  or  knee.  The  patient  was  now  i)laced 
in  the  supine  position.  It  was  found  that  the  affected  knee  joint 
was  slightly  warmer  than  its  fellow,  and  tliat  there  was  an  almost 
complete  obliteration  of  the  fossje  on  either  side  of  the  patella. 
There  was  tenderness  on  pressure  over  the  condyles  of  the 
femur,  and  below,  over  the  ligamentum  patellae.  This  tenderness 
was  not  present  on  the  opposite  side.  The  limb  was  then  exam- 
ined as  to  the  passive  mobility  of  the  hip  and  knee  joints.  When 
the  limb  was  moved  as  a  whole,  with  the  knee  in  its  acquired 
position,  no  muscular  rigidity  existed  at  the  hip.  But  if  the 
attempt  was  made  to  flex  the  thigh  on  the  pelvis,  at  the  expense 
of  motion  at  the  knee,  a  very  decided  resistance  was  experienced 
at  the  hip.  When  the  attempt  was  made  to  flex  or  extend  the 
knee,  it  was  found  to  be  rigidly  held  in  its  deformed  position  by 
a  very  decided  muscular  contraction,  and  when  a  slight  degree 
of  force  was  used,  the  joint  refused  to  yield,  and  the  ])atient 
gave  evidence  of  pain,  both  by  facial  expression  and  orally.  The 
pain  was  referred  to  the  inner  side  of  the  joint.  A  persistent 
attem])t  to  flex  the  leg  on  the  thigh,  using  a  continuous  rather 
than  a  great  degree  of  force,  was  followed  by  a  very  ])erce])tible, 
almost  audible  "click,"  which,  Dr.  Seymour  remarked,  reminded 
him   of   the    sensation    imparted  to   the   hand   as    a  knife    blade 


HYSTERICAL  JOINT  AFFECTIONS.  9 

passes  its  half  opened  position.  Motion  now,  inside  of  the 
degree  of  flexion  at  which  the  limb  had  been  habitually  held, 
was  free  and  unaccompanied  by  pain,  but  any  attempt  to  extend 
the  limb  past  its  usual  stopping  point,  was  met  by  a  decided 
muscular  resistance,  and  apparently  gave  pain. 

Persisting  as  before,  and  using  a  continuous  force,  gradually 
increasing  it,  and  diverting  the  patient's  mind  in  the  meantime  by 
telling  her  an  amusing  story,  the  leg  passed  the  apparent  obstruc- 
tion, again  accompanied  by  the  "  click."  Now,  again,  we  found 
free  movement.  These  manipulations  were  repeated  many  times, 
and  always  with  the  same  result.  The  leg  would  be  arrested, 
either  in  flexion  or  extension,  at  exactly  the  same  point,  and  the 
suggestive  "  click"  would  invariably  occur  as  this  point  was 
passed.  After  these  manipulations  the  patient  was  asked  to 
move  about  the  room.  It  was  found  that  she  could  walk  belter 
than  before.  I  may  remark  also  that  during  the  examination 
the  patient  showed  considerable  emotion,  which  did  not,  how- 
ever, find  expression  in  tears. 

There  were  no  hyperjesthetic  spots  over  the  spine.  There  was- 
no  history  of  masturbation,  and  the  genital  organs  showed  no 
evidences  of  irritation.  The  child  had  always  been  mentally 
over-active  for  her  years,  and  there  was  nothing  of  importance 
developed  in  the  hereditary  history.  Her  general  health  had 
always  been  good,  with  the  exception  of  the  usual  diseases  of 
childhood,  which  she  had  always  borne  well.  There  was  a  his- 
tory of  disturbed  sleep. 

The  previous  treatment  of  the  case  included  counter-irritation 
and  almost  perfect  quiet  of  the  affected  limb.  What  proved  to 
be  over  anxiety  on  the  part  of  the  parents  and  friends  of  the 
patient,  had  directed  a  great  deal  of  attention  to  the  child,  who 
in  her  emotional  condition  was,  not  unnaturally  perhaps,  not 
averse  to  this  excess  of  attention. 

Remarks. — The  differential  diagnosis  involved  a  consider- 
ation of  three  conditions — the  hip  being  excluded,  as  no 
positive  symptoms  of  any  lesion  of  this  articulation  pre- 
sented. I.  An  osteitis  or  chondritis  of  the  knee,  following 
some  injury  to  the  cartilage  at  the  time  of  the  accident, 
and  which  would  account  for  the  "click."  II.  A.  chronic 
synovitis,  not  involving  the  bone,  but  attended  with  anom- 


lO  NEWTON  M.   SHAFFER. 

aloLis  symptoms.  III.  A  neuromimesis.  After  duly  con- 
sidering these  conditions,  the  last  was  diagnosed,  and,  for 
the  following  reasons : 

1st.  A  traumatism  sufficient  to  lacerate  the  cartilage,  and 
cause  a  mechanical  impediment  to  motion,  would  have  been 
attended  with  urgent,  acute  symptoms.  2dly.  An  osteitis 
dependent  upon  an  injury  or  otherwise,  would  have  been 
followed  by  more  expressive  symptoms,  and  the  muscular 
rigidity  would  have  been  uniformly  present,  and  would 
have  prevented  motion  in  the  extremes  of  flexion  and  ex- 
tension— not  at  a  point  between  these  extremes.  3dly.  The 
swelling  was  subcutaneous,  and,  as  was  afterwards  proven, 
due  to  the  effect  of  the  counter  irritation,  thus  eliminating 
the  synovial  membrane  from  implication.  4thly.  The  pain 
was  demonstrated  to  be  hypersesthetic,  and  the  heat  was 
inferentially  supposed  to  be  a  simple,  local  hyperaemia,  due 
to  the  counter  irritation.  As  it  disappeared  in  a  few  days, 
this  supposition  seemed  correct.  5thly.  The  child  was  very 
emotional  during  examination,  and  would  permit  various 
movements  of  the  limb  when  her  attention  was  directed  to 
other  matters,  which  motions  she  would  not  allow  when  her 
mind  was  concentrated  upon  the  joint.  6thly.  The  atrophy 
was  no  more  than  would  result  from  the  enforced  disuse  of 
the  limb  for  several  weeks,  /thly.  The  limp,  attitude,  etc., 
were  the  result  of  the  position  of  the  joint,  which  position, 
though  fixed  during  the  day,  was  modified  during  sleep, 
free  movement  of  the  articulation  being  then  possible  with- 
out the  "  click." 

I  have  attempted  to  explain  the  peculiar  "  click,"  which 
forms  the  prominent  peculiarity  of  the  case,  by  supposing 
it  to  be  due  to  the  reduction  of  a  temporarily  displaced 
tendon,  or  perhaps  to  the  reduction  of  a  slight  subluxation, 
in  either  event  caused  by  muscular  action.  This  latter 
condition  I  have  seen  in  one  other  case. 


HYSTERICAL  JOINT  AFFECTIONS.  I  I 

The  diag'nosis  was  a  surprise  to  the  mother  of  the  pa- 
tient, for  she  had  been  led  to  infer,  upon  what  we  all  would 
esteem  good  authority,  that  a  serious  chronic  inflamma- 
tion of  the  hip  joint  existed.  Dr.  Seymour  wholly  coin- 
cided with  me  in  my  opinion.  The  parents  were  directed 
to  stop  all  local  treatment,  excepting  daily  manipulation  of 
the  joint.  The  child  was  not  to  be  asked  any  questions 
regarding  her  knee,  and  the  excess  of  attention  she  had 
received  was  to  be  discontinued.  The  patient's  thoughts 
were  to  be  diverted  from  herself;  plenty  of  exercise  in 
the  open  air  was  insisted  on,  and  a  general  tonic  course 
of  medication  was  advised.  A  few  months  later  the 
mother  of  the  patient  called  upon  me,  and  stated  that 
for  a  few  weeks  only  slight  improvement  was  noticed, 
but  that  afterward,  under  the  stimulus  of  a  promise  that 
if  the  patient  would  walk  "  perfectly  straight  "  by  a  cer- 
tain time  she  might  attend  a  Sunday-school  festival  in 
which  she  was  greatly  interested,  the  improvement  became 
more  rapid.  She  did  walk  without  any  limp  ;  there  was  no 
pain,  and  the  recovery  was  complete.  There  has  been  no 
return  of  the  trouble  since  that  date. 

This  patient  exhibited  symptoms  which  would  suggest  a 
primary  local  lesion  of  the  knee  joint  involving  the  vascular 
system,  heat,  swelling,  redness  of  the  cuticle,  and  pain,  fol- 
lowing an  injury;  adding  to  these,  immobility  of  the  articu- 
lation, limping,  muscular  atrophy  and  disturbed  sleep,  and 
all  the  important  symptoms  necessary  to  a  diagnosis  of 
chronic  disease  of  the  joint  were  present. 

Case  2. — G.  L.  R.,  a  boy  of  12  years  consulted  me  on  Novem- 
ber 25,  1878,  introduced  by  letter  from  a  prominent  surgeon  of 
western  New  York.  The  patient  came  into  my  office  leaning  on 
the  arm  of  an  attendant,  limping  very  badly  and  complaining 
greatly  of  his  left  knee. 

Inquiry  developed  no  tendency  to  hereditary  disease  of  tlie  ar- 
ticulations, no  history  ot   phthisis  or  rheumatism,  and  there   was 


12  NEWTON  M.   SHAFFER. 

nothing  of  importance  in  his  early  history, — he  had  always  been 
a  healthy,  though  not  a  rugged  boy. 

In  February,  1878,  the  patient  fell  upon  the^  ice  in  front  of  his 
home,  striking  upon  his  knee-joint.  The  injury  was  quite  severe 
and  the  boy  was  carried  into  the  house.  There  was  great  pain, 
followed  by  ecchymosis  and  some  heat  and  swelling.  These 
symptoms  continued  for  a  few  days,  and  after  their  most  acute 
phase  subsided,  there  was  more  or  less  pain  on  moving  the  joint, 
with  swelling  at  the  point  of  injury.  He  remained  in  bed  for  five 
weeks,  and  for  the  two  or  three  weeks  following  he  was  dressed, 
but  hobbled  around  saving,  in  every  possible  way,  the  affected 
joint.  Finally,  about  ten  weeks  after  the  injury  he  walked  as  well 
as  ever,  and  during  the  spring  and  summer  walked  to  and  from 
school  daily,  a  distance  of  four  miles. 

On  October  loth,  he  went  on  an  errand  for  his  mother,  and  on 
his  return  his  knee  pained  him  very  much  and  he  was  obliged  to 
stop  walking.  After  this,  he  "hopped  around,"  always  holding 
the  leg  flexed  on  the  thigh  in  one  position.  From  October  loth 
to  November  25th,  (the  day  he  consulted  me),  he  had  not  been 
out  of  doors,  except  to  come  to  the  city.  'Inhere  had  been  no 
acute  pain  in  the  joint  when  it  was  at  rest,  but  any  sudden  motion 
produced  "  sharp  pain  :  "  he  had  slept  tolerably  well  ;  there  was 
considerable  atrophy  of  the  thigh  and  the  leg  muscles  and  the 
boy  was  thin  and  anaemic  and,  evidently,  very  apprehensive  about 
his  knee.  The  joint  was  held  quite  rigidly  by  muscular  action  in 
tine  extremes  of  flexion  and  extension,  but  examination  proved 
that  no  real  muscular  spasm  existed  :  the  joint  could  be  flexed 
and  extended  normally  by  persistently  using  a  very  moderate 
degree  of  force,  though  the  attendant  states  that  the  position 
of  the  leg  was  not  modified  during  sleep. 

The  patient  gave  a  history  of  mental  overwork  :  had  studied 
hard  and  for  several  years  :  tastes  had  always  been  effeminate — al- 
ways very  gentle  in  his  play,  preferring  the  society  of  girls  to  that 
of  boys  of  his  own  age  ;  not  emotional  as  to  tears,  but  is  what 
would  be  called  "  a  nervous  boy." 

Remarks. — My  comments  on  this  case  will  consist  simply 
of  extracts  from  the  letter  which  I  sent  to  the  family  physi- 
cian :  "  I  may  summarize  the  results  of  my  examination  as 
follows: — no  marked  pain  on  motion  which  was  not  limited 
by  any  reflex  muscular  spasm,  though  the  spasm  was  closely 


H  YS  TERICA  L  JOIN  T  A  FFE  C  7  IONS.  I  3 

imitated  in  the  extremes  of  flexion  and  extension :  no 
strictly  involuntary  symptoms  at  all,  either  nocturnal  or 
diurnal :  no  swelling  except,  perhaps,  a  very  slight  one  under 
the  ligamentum  patella;,  where  the  thickness  of  the  cuticle 
(from  iodine)  made  palpation  very  unsatisfactory:  local 
temperature  2°  lower  than  on  opposite  side :  electrical  reac- 
tion of  muscles  of  leg  and  thigh  normal,  the  same  on  either 
side:  defective  nutrition  of  limb  due  to  disuse  solely."    *  * 

"  The  boy  is  mentally  very  acute  and  physically  very 
sluggish.  I  find  he  is  inclined  to  avoid  boyish  occupations 
and  consider  his  lack  of  stamina  and  pasty  complexion  to 
be  not  of  the  strumous  sort.  In  some  respects  our  patient 
is  what  may  be  called  a  typically  neurotic  boy." 

"  I  would  advise  a  gradual  increase  in  the  use  of  the  joint 
and  limb,  for  a  few  days  passively  using  electricity,  mas- 
sage, etc.,  and  then  I  would  put  the  patient  on  his  own  re- 
sources entirely :  he  is  to  be  asked  no  questions  as  to  his 
feelings  or  sensations:  give  also,  a  thorough  course  of  iron, 
cod-liver  oil  and  malt,  and  keep  the  boy  out  of  school  and 
at  out-door  sports  for  at  least  one  year." 

The  patient  wholly  recovered  in  a  few  weeks  and  has 
grown  six  inches  since  I  saw  him. 

A  diagnosis  of  chronic  joint  disease  had  been  made  in 
this  case  by  a  prominent  surgeon,  whose  contributions  to 
surgery  have  more  than  once  been  quoted  abroad,  and  this 
gentleman  was  about  to  apply  apparatus  to  the  patient,  rest 
and  counter  irritation  having  resulted  only  in  an  increase  of 
the  symptoms. 

Case  3. — Miss  K.,  a  young  lady  of  good  physique,  residing  in 
New  Jersey,  consulted  me  in  February,  1878,  in  reference  to  what 
were  apparently  severe  and  urgent  symptoms  of  disease  of  the 
knee  joint,  the  patient  presenting  herself  on  crutches. 

She  gave  the  following  history  : — About  four  years  ago  she  be- 
gan to  have  pains  occasionally  in  the  left  knee  :  they  were  very 
acute,  occurred  at  irregular  intervals  and  were  increased  by  walk- 
ing.    There  was  no  limping  at  first.     The  pains  came  a,nd  went 


14  NEWTON  M.   SHAFFER. 

without  any  recognized  cause  and  were  as  frequent  at  night  as  by 
day.  She  never  awoke  with  pain  and  was,  as  a  rule,  free  from  it 
up  to  9.30  o'clock,  A.M.,  when  it  would  generally  occur  :  there 
was  never  any  swelling  of  the  joint  which  the  patient  could 
detect,  though  it  was  frequently  hotter  than  the  sound  one  :  she 
was  always  able  to  move  the  joint  with  more  or  less  freedom  though 
at  times  with  considerable  pain  :  passive  motion  was  accompanied 
by  considerable  resistance  in  the  extremes  of  flexion  and  ex- 
tension. After  some  months  the  symptoms  became  worse  and 
the  family  physician  ordered  crutches,  which  the  patient  has  ever 
since  used,  without,  however,  the  relief  which  was  anticipated. 
Accompanying  these  local  symptoms  were  other  manifestations, 
affecting,  especially,  the  head  and  neck.  The  sensations  here 
were  those  of  "  trouble  in  the  back  of  the  neck  " — pain,  not  in- 
creased by  motion,  a  sensation  of  heat  "  like  a  hot  plate,"  in  the 
cervical  region,  but  no  headache.  It  sometimes  happened  that 
when  the  knee  did  not  ache,  the  neck  did,  and  vice  vejsa.  The 
pain  in  the  knee  was  not  superficial  but  was  referred  to  the  very 
"  centre  of  the  joint."  It  was  either  a  "  gnawing  or  a  lancinating 
pain  :  " — there  were  no  hyper^sthetic  areas  and,  at  the  time  of 
the  examination,  the  local  and  general  temperatures  were  normal. 
The  ])atient  did  not  look  at  all  ill,  and  there  were  no  facial  traces 
of  suffering  so  frequeni^ly  seen  in  chronic  osteitis  of  the  joint 
ends  :  but  there  was  hereditary  history  of  phthisis,  the  mother 
having  died  therefrom.  The  case  had  been  under  the  care  of 
one  who  would  be  recognized  as  a  competent  observer,  who, 
attributing  too  much  weight,  in  the  absence  of  specific  symp- 
toms, to  the  phthisical  history,  had  made  a  diagnosis  of  incipient 
osteitis  of  the  knee.  There  were  symptoms  which  suggested  this 
lesion,  but  like  all  purely  neurotic  symptoms,  they  were  extremely 
irregular  and  inconstant,  and  this  very  element  was  the  basis 
of  an   exclusive  diagnosis  in  the  case. 

The  crutches  were  dispensed  with  and  the  patient,  who  was  an 
indefatigable  teacher,  was  removed  from  her  routine  duties.  It 
took  the  patient  five  days  only  to  discontinue  the  crutches, 
though  she  had  used  them  continuously  for  months  and  had  not 
gone  out  of  the  house  for  the  three  months  preceding  Christmas, 
1877  : — this  discontinuance  did  not  produce  pain  and  their  ab- 
sence, after  the  novelty  wore  off,  was  pleasant  rather  than  other- 
wise. During  the  past  summer  the  patient  has  been  at  the  sea- 
side and  among  the  mountains,  has  used  no  artificial  support 
whatever,  and   has   returned  greatly  improved. 


//  YS TERICA L  JOINT  A FFE C TIONS.  I  5 

I  may  remark  that  this  case  is  typical  of  that  kind  of 
"hysteria"  which  develops  in  those  who  are  physically  ro- 
bust, but  who  are  subjected  in  their  occupations  to  con- 
stant physical  and  mental  strain.  This  lady  filled  an  im- 
portant position  in  a  large  school  and  gave  almost  incessant 
attention  to  her  duties.  I  draw  attention  to  this  and,  in 
noting  the  absence  of  any  history  of  traumatic  influence,  to 
the  difference  that  exists  between  the  simulated  joint 
lesions  dependent  on  mental  overwork  and  strictly  emo- 
tional cases  with  the  history  of  traumatism.  In  the  first 
there  are  symptoms  which  find  a  local  expression  in  other 
parts  of  the  body,  while  in  Cases  i  and  2,  there  are  first 
local  injuries  through  which  the  fear  and  other  emotions  of 
the  patient  seem  to  find  an  exit. 

During  the  fall  of  1875  my  attention  was  especially  di- 
rected by  a  case  which  occurred  in  my  service  at  the  Ortho- 
paedic Dispensary  (Case  4)  to  the  fact — which  I  had  before 
noted — that  the  expressive  muscular  atrophy  which  occurs 
in  morbus  coxarius  did  not  exist  in  the  hysterical  state 
which  simulated  it.  In  this  particular  case  a  slight  atrophy 
only  occurred  even  after  several  weeks  of  treatment  which 
involved  complete  disuse  of  the  limb  and  the  pressure  of  ad- 
hesive plasters  and  bandaging,  all  of  which  are  the  necessary 
accompaniments  of  the  mechanical  treatment.  This  led  me 
to  investigate  the  electrical  condition  of  the  muscles  in 
both  the  hysterical  and  diseased  conditions  of  the  hip  joint 
especially.  The  result  was  that  in  the  former  I  found  in  all 
the  cases  I  examined  a  normal  degree  of  muscular  contrac- 
tion in  response  to  the  faradic  current,  while  in  the  latter, 
even  in  the  earliest  stages,  and  apparently  coincidental  with 
the  first  appearance  of  the  reflex  muscular  spasm,  there  was 
a  marked  reduction.  After  many  experiments,  including 
the  same  tests  as  applied  to  voluntarily  tetanized  muscles, 
and  which  showed  a  normal  reaction  like  the  hysterical,  and 


1 6  NEWTON  M.   SHAFFER. 

all  of  which  uniformly  led  to  the  same  conclusions,  I  in- 
vited my  friend,  Dr,  E.  C.  Seguin,  to  apply  the  same  test  to 
several  cases  of  hip  joint  disease.  This  he  did  on  May  17, 
1877,  and  the  result  of  my  own  observations,  sustained  by 
Dr.  Seguin's  experiment,  are  duly  recorded  in  the  Archives 
of  Clinical  Surgery,  for  June,  1877.  From  this  article*  I 
may  be  permitted  to  quote  the  following  sentences  :  "  The 
atrophy  which  occurs  from  simple  functional  inertia,  com- 
bined with  the  pressure  produced  by  adhesive  plaster  and 
bandaging,  is  witnessed  when  the  not  infrequent  error  is 
made  of  treating  by  these  means  and  an  apparatus,  a  neu- 
romimesis  of  a  joint  lesion,  for  the  real  disease.  This  sim- 
ple atrophy  following  disuse  and  pressure  is  altogether  dif- 
ferent from  that  which  ensues  from  an  actual  joint  lesion, 
and  is  unaccompanied  by  a  loss  of  electro-muscular  con- 
tractility." 

These  observations  were  based  wholly  upon  original  re- 
search, and  while,  so  far  as  I  know,  I  was  the  first  to  apply 
the  electrical  test  as  an  aid  in  the  differential  diagnosis  of 
true  and  false  joint  diseases,  it  remains  for  me,  as  a  matter 
of  justice  to  Charcot  and  Esmarch,  as  well  as  to  myself,  to 
state  that  Charcot  mentions  that  in  a  case  of  hysterical  con- 
tracture "  the  electrical  contractility  of  the  muscles  has 
remained  nearly  normal,"  and  Esmarch,  in  his  essay  on 
"  Gelenkneurosen  "  remarks,  "  Notwithstanding,  the  muscles 
ma  ntain  a  well  nourished  condition,  and  retain  after  long 
disuse,  their  electrical  reaction."  At  the  same  time  I  was 
studying  this  subject.  Dr.  Emile  Valtat  of  Paris,  was  en- 
gaged in  experimentally  demonstrating  the  muscular  atro- 
phy of  joint  disease  t  and  reached  in  some  respects  the 
same  conclusions  as  my  own,  as  applied   to   the  condition 


*  Reflux  Muscular  Conlraclioii  and  Atropliy  in  Joint  Disease,  etc.,  by- 
Newton  M.  Shaffer,  M.D. 

f  I)e  r Atrophic  musculaire  consecutive  aux  maladies  des  articulations, 
Paris,  1877. 


//  VS  TERICA  L  JOIN  T  A  FFE  C  TIO  MS.  1 7 

of  actual  disease.  After  these  statements  it  becomes  un- 
necessary for  me  to  call  attention  to  the  value  of  the  faradic 
current,  as  a  means  of  precision,  in  the  diagnosis  of  the  neu- 
romimetic  condition. 

In  Seguin's  "  Series  of  American  Clinical  Lectures,"*  I 
have  given  parallel  tables  showing  the  differential  points 
in  diagnosis  of  typical  cases  of  chronic  synovitis  and 
chronic  osteitis  of  the  knee  joint.  I  will  reproduce  them 
here,  make  one  or  two  additions  to  them,  and  follow  them 
with  remarks  on  the  diagnosis  of  the  neuromimetic  state, 
as  applied  to  the  same  articulation. 


CHRONIC     SYNOVITIS    OF     THE 
KNEE    JOINT. 

I.     Capsule  thickened, — Ef- 
fusion marked. 


2.  Natural  contour  of  leg 
and  thigh, — Joint  outline  ob- 
literated. 


3.     Motion     extensive      and 
nearly    normal. 


4.  Resistance  to  motion 
elastic,  and  efforts  to  over- 
come it  not  productive  of  pain. 


5.     No  reflex  muscular  spasm 
present. 


6.     No  pain  present,  nor  pro- 
duced by  forcible  tests. 


7.     No   perceptible   limp    or 
hesitation  in  walkina;. 


CHRONIC     ARTICULAR     OSTEITIS 
OF  THE  KNEE    JOINT. 

I.  No  thickening  of  capsule 
evident, — No  sense  of  fluctua- 
tion. 


2.  Muscular  atrophy  mark- 
ed,— Joint  outline  clear  and  dis- 
tinct,— Joint  appears  large,  on 
account  of  the  diminished  size 
of  both  thigh  and  leg. 


Motion  ;///. 


4.     Joint  held  perfectly  rigid 
by  muscular  action  alone. 


5.  Reflex  muscular  spasm 
affecting  both  flexors  and  ex- 
tensors. 


6.  Acute  pain  upon  the 
slightest  attempts  at  joint 
motion. 


7.     Unable     to    walk     from 
pain    and    deformity. 


*  The  Etiology  and  Pathology  of  Chronic  Joint  Disease.      Vol.  iii,  no.  vi. 


i8 


NE  WTON  M.   SHAFFER. 


CHRONIC     SYNOVITIS     OF      THE 
KNEE  JOINT. 

8.     Sleep  normal, — No  reflex 
osteitic  cry. 


9.     Femur  and  tibia  in  nor- 
mal relation  to  each  other. 


10.  Symptoms  local,  so  far  as 
those  dependent  on  the  joint 
lesion  are  concerned. 


II.  The  superficial  tissues 
over  the  joint  may  be  either 
slightly  warmer,  or  the  same  as 
the  healthy  joint. 


12.  Electrical  contractility  of 
leg  and  thigh  muscles  not  im- 
paired before  the  occurrence  of 
the  reflex  muscular  spasm. 


CHRONIC     ARTICULAR     OSTEITIS 
OF    THE    KNEE  JOINT. 


8.  Incoherent 
"  starting  pains, 
during   sleep. 


cries      and 
occurring 


9.  Tibia  subluxated  back- 
ward (partial)  by  muscular 
action. 

10.  General  and  local  neural 
symptoms  directly  referable  to 
the  joint  lesion. 


II.  Local  temperature  rarely 
lower  than  normal — almost  al- 
ways increased  from  )^°  to  3°. 


12.  Electrical  contractility  of 
leg  and  thigh,  muscles  reduced  ; 
— in  many  cases  remarkably  so, 
even  in  the  early  stage. 


13.  The  reflex  muscular  spasm 
is  not  modified  during  sleep — 
nor  does  it  yield  to  the  ordinary 
doses  of  opium  or  chloral. — It 
will  yield,  however,  wholly  to 
the  profound  anaesthesia  of 
ether  or  chloroform. 


We  will  now  consider  the  various  points  in  this  table  as 
applied  to  the  hysterical  condition  of  the  same  articulation  ; 
first,  however,  calling  attention  to  the  fact  that  in  certain 
conditions  a  hysterical  contracture  may  exist,  especially  in 
adults,  which  more  closely  resembles  the  typical  reflex 
spasm  of  chronic  osteitis,  than  the  emotional  contraction, 
which  I  have  attempted  to  describe.  This  contracture  will 
be  specially  considered  later. 

I.  Thickening  over  the  joint  may  or  may  not  be  present ; 
when  present,  it  is  very  evidently  confined  to  the  cellular 
tissue  only,  and  is  generally  accompanied  by  hyper^emia 
and  hypera^sthetic  areas,  which  latter  are  not,  as  a  rule,  con- 


HYS  T ERIC  A  L  JOIN  T  A  FFE  C  TIONS.  1 9 

fined  to  the  immediate  region  of  the  joint,  or  to  points 
where  tenderness  should  be  developed  by  pressure  either  in 
synovitis  or  osteitis. 

2.  Atrophy  from  disuse  only  ;  not  the  expressive  wasting 
of  chronic  osteitis. 

3,  4  and  5.  The  joint  may  possess  even  an  abnormal 
degree  of  mobility,  as  in  hysterical  paralysis,  but  it  will 
generally  be  found  that  motion  is  impeded  at  first  by  mus- 
cular action,  which  may  either  closely  resemble  the  tetanoid 
spasm  of  osteitis,  holding  the  joint  absolutely  rigid  at  a 
fixed  point,  as  in  Case  i,  or  it  may  permit  joint  move- 
ments, which  are  arrested  just  inside  of  the  extremes  of 
flexion  or  extension,  as  in  Cases  2  and  3.  In  any  event  per- 
sistent effort,  in  the  meantime  diverting  the  patient's  atten- 
tion, will  wholly  overcome  the  muscular  resistance.  If  the 
patient  be  examined  on  two  or  three  occasions,  the  mus- 
cular conditions  may  be  found  variable,  and  certain  move- 
ments which  the  patient  will  almost  invariably  resist  under 
passive  examination,  will  be  voluntarily  executed  when  the 
patient  imagines  himself  unobserved. 

6.  Pain  may  be  apparently  very  severe,  and  at  points 
where  it  usually  exists  in  osteitis.  Generally,  however,  this 
pain  is  just  as  severe  when  the  subcutaneous  tissues  are 
slightly  pinched,  as  when  firm  pressure  is  made.  In  some 
instances  pain  can  be  developed  at  any  point  by  simply 
directing  the  patient's  attention  to  it.  The  oral  expression 
of  pain  is  wholly  different  in  the  hysterical  condition  from 
that  which  occurs  in  osteitis.  In  the  former  it  partakes 
more  of  the  voluntary  character ;  the  latter  is  invohintary,. 
and  is  accompanied  by  a  facial  expression  which  cannot  be 
counterfeited. 

7.  There  is  always  a  limp  if  the  limb  is  used  at  all.  In 
many  cases  the  fears  of  the  patient,  reinforced  by  the  ap- 
prehensions of  the  physician,  place  the  patient  on  crutches 


20  NE  WTON  M.   SHAFFER. 

or  in  a  splint.  The  limp  may  closely  resemble  that  of 
osteitis,  or  it  may  partake  of  the  character  imparted  by 
congenital  dislocation  of  the  hip.  If  examined  with  care, 
however,  there  will  always  be  found  a  sort  of  exaggeration 
about  the  gait,  and  in  some  cases  the  patient,  under  some 
stimulus,  will  involuntarily  resume  command  of  the  hysteri- 
cal muscles,  and  walk  well  for  a  few  moments. 

8.  Sleep  may  be  disturbed.  In  the  majority  of  cases,  it 
is  normal.  An  incoherent  cry,  resembling  that  of  osteitis, 
occurred  at  night  in  one  of  my  cases,  but  it  was  evidently 
due  to  intestinal  irritation.  The  "  starting  pains  "  do  not 
occur  in  neuromimesis.  Consciousness  is  necessary  to  form 
the  group  of  symptoms  which  we  are  studying  now. 

9.  The  position  of  the  limb  is,  as  a  rule,  flexed — 
though  I  have  seen  it  held  in  extreme  extension — a  posi- 
tion which  Esmarch  says  is  ver}^  frequent.  At  night,  dur- 
ing sleep,  the  malposition  may  be,  almost  always,  readily 
overcome. 

10.  In  almost  every  case  the  patient  will  be  found  to  be 
emotional  to  a  greater  or  less  degree,  and  there  will  exist 
some  general  or  specific  evidence  of  this  condition  in  the 
history,  conduct  or  appearance  of  the  patient. 

11.  If  the  affected  joint  be  hotter,  a  superficial  hyperae- 
mia  exists.  In  Case  i  it  did  exist,  and  was  apparently  due 
to  the  counter  irritants  employed ;  and  yet  in  Case  2,  where 
counter  irritants  had  been  thoroughly  used,  the  local  tem- 
perature was  2°  lower.  In  two  other  knee  cases,  not  re- 
ported, there  was  a  reduction  of  2°  in  one  and  i^°  in  the 
other.  The  hyperaemia  of  neuromimesis,  is  apt  to  dis- 
appear and  again  reappear,  while  the  temperature  of  an 
inflamed   joint  varies  but  little  from  day  to  day. 

12.  In  the  hysterical  joint,  the  muscles  retain  their  nor- 
mal contractility,  as  tested  with  the  faradic  current.  Even 
if  the  hysteric   contraction   has  existed  for  a  long  time,  the 


//  VS  TERI CA  L  JOIN  T  A  FFE  C  TIONS.  2 1 

faradic  current  shows  little  or  no  reduction  either  in  the 
muscle  or  nerve  currents. 

13.  A  full  dose  of  opium  or  chloral  will  cause  the  mus- 
cular contraction  to  yield,  should  it  apparently  resist  in  na- 
tural sleep. 

From  these  facts  it  will  be  seen  that  all  the  impor- 
tant symptoms  of  disease  of  the  knee  joint  may  occur 
in  a  neuromimesis.  But  from  a  comparison  of  these  dif- 
ferential statements  we  may  draw  the  following  conclu- 
sions regarding  both  the  true  and  false  knee  joint  condi- 
tions: 

I.  The  neuromimetic  condition  resembles  both  the 
chronic  inflammation  of  the  synovial  membrane  and  the 
bone.  If  it  be  remembered,  however,  that  the  changes 
which  take  place  in  chronic  synovitis  produce  very  few,  if 
any,  subjective  symptoms,  while  the  objective  are  promi- 
nent, as  applied  to  the  joint  itself ;  and  that  the  hysterical 
imitation  presents  a  long  train  of  both  subjective  and  ob- 
jective symptoms  and  signs,  with  the  former  in  excess,  but 
little  difficulty  will  be  experienced  in  making  a  differential 
diagnosis. 

II.  If  the  following  conditions  exist,  a  diagnosis  of 
chronic  osteitis  of  the  knee-joint  may  be  made  with  cer- 
tainty : 

1st.  A  muscular  spasm,  which  cannot  be  overcome  by 
persistent  effort,  while  the  patient's  mind  is  diverted — a 
spasm  that  does  not  vary  night  or  day,  whether  affecting 
motion  in  the  extremes  of  flexion  and  extension  only,  or 
simulating  an  actual  synostosis — a  spasm  which  is  not  affect- 
ed by  the  ordinary  doses  of  opium  or  chloral,  and  which 
yields  to  profound  ansesthesia  only.  2dly.  A  markedly  re- 
duced faradic  reaction  of  the  muscles  thus  affected.  3dly. 
A  localized  and  uniform  rise  of  temperature  over  the  af- 
fected articulation.      4thly.  The  presence  of  purely  involnn- 


22  NEWTON  M.    SHAFFER. 

tary  neural  symptoms,  as  shown  above,  in  the  reflex  mus- 
cular spasm,  the  starting  pain,  the  osteitic  cry,  etc. 

III.  If  the  following  conditions  are  found,  a  diagnosis  of 
hysterical  knee  joint  disease  may  be  made  with  equal  cer- 
tainty:  1st.  A  variable  muscular  rigidity  or  contraction 
which  can  be  overcome  by  mildly  persistent  effort,  while  the 
patient's  mind  is  diverted,  or  which  yields  during  natural 
sleep,  or  which  wholly  disappears  under  the  usual  doses  of 
opium  or  chloral.  2dly.  A  normal  reaction  of  these  con- 
tracted muscles  in  response  to  the  faradic  current.  Sdly. 
The  absence  of  a  rise  of  temperature,  or  especially  the  pres- 
ence of  a  reduced  temperature  over  the  affected  joint. 
4thly.  The  presence  of  various  emotional  and  semi-volun- 
tary manifestations,  which  are  variable  and  inconstant — 
the  variability  and  inconstancy  being  due  to  the  different 
conditions  of  the  emotions,  as  affected  principally  by  voli- 
tion. 

We  will  now  consider  neuromimesis  of  hip-joint  disease. 

Case  4. — Fanny  A.  is  15  years  old,  and  lives  in  New  York. 

Hereditary  history. — Father  an  epileptic  ;  is  an  inmate  of  the 
Blackwell's  Island  Hospital  for  Epileptics,  and  "is  fast  becoming 
an  idiot."  Mother  is  healthy  ;  the  patient  has  one  brother  who  is 
well  ;  no  sisters. 

Patient  is  a  plump  girl  ;  has  a  clear  skin,  and  is  not  anaemic  ;  is  an 
inmate  of  a  Home  for  Friendless  Girls,  and  applied  for  relief  at  the 
Orthopaedic  Dispensary  Aug.  3,  1875,  accompanied  by  the  matron 
of  the  Home.  Six  montlis  previously,  while  in  domestic  service 
which  required  much  running  up  and  down  stairs,  she  was  attack- 
ed by  a  severe  pain  in  the  knee  of  the  right  leg,  attended  by  a 
very  perceptible  limp.  The  pain  soon  involved  the  hip-joint,  and 
finally  the  back.  The  pain  was  frequently  urgent  at  night,  and 
"  the  leg  was  drawn  up  and  in  "  both  night  and  day.  There  was 
no  history  of  any  direct  injury  to  the  affected  limb  or  joint. 

The  patient  applied  at  the  dispensary  during  my  summer  vaca- 
tion, and  the  following  notes  were  made  in  the  record  book  by  the 
assistant  surgeon  who  received  the  case  : 

"  Condition  of  limb,  adducted  and  slightly  flexed  ;  muscular 
*  Read  before  the  New  York  Neurological  Society,  December  i,  1879. 


HYSTERICAL  JOINT  AFFECTIONS.  23 

rigidity  and  pain  at  thigh  and  knee  ;  flattening  of  natis  and  alter- 
ation of  gluteo-femoral  crease.  Pressure  through  trochanters 
gives  pain  ;  motion  in  any  direction,  especially  adduction  and  ab- 
duction is  resisted  and  gives  pain.  Pain  on  going  up  and  down 
stairs  ;  pain  at  night  ;  limps  badly  ;  slight  concussion  to  heel 
causes  apparently  severe  pain.  Menstruation  regular  and  normal. 
General  condition  of  patient  seems  excellent ;  she  came  into  the 
room  bearing  almost  her  entire  weight  upon  the  arm  of  her  at- 
tendant." 

A  diagnosis  of  hip  disease  was  made  by  the  assistant  surgeon, 
and  a  note  to  that  effect  was  sent  to  the  managers  of  the 
''  Home." 

On  August  16,  1876,  the  hip  splint  was  applied.     On  the  20th 
the  following  record  was  made  in  the  history  book  : 
"Relieved  of  pain  ;  walks  very  nicely  with  the  splint." 
August  28th. — "  Muscular  rigidity  still  well  marked." 
September  irth. — "Doing  well."      September  15th. — "Exam- 
ined to-day  very  carefully  by  the  surgeon  in  charge,  and  hysterical 
symptoms  established  beyond  doubt.      Splint  and   appurtenances 
removed  and  patient  ordered  to  walk  home." 

"  The  following  conditions  were  present  during  the  examination  : 
Patient,  under  the  instructions  of  the  operator,  voluntarily  flexed, 
extended,  abducted  and  adducted  the  limb  normally.  She  re- 
sisted at  first,  but  gradually  yielded  and  permitted  the  operator  to 
place  the  limb  in  the  extreme  positions  mentioned  above,  includ- 
ing also  all  degrees  of  rotation  and  circumduction.  Pain  only  on 
pressure  over  anterior  superior  spine  and  above  crest  of  ilium. 
The  patient  walked  away  without  apparatus,  and  with  slight  limp." 
No  special  treatment  was  adopted.  She  was  ordered  to  use  passive 
movements,  a  tonic  was  prescribed,  and  the  case  was  kept  under 
observation.  On  October  ist  of  the  same  year  she  went  to  Hast- 
ings-on-the-Hudson  to  fill  the  position  of  a  domestic,  wholly  cured, 
and  there  was  no  return  of  the  trouble  even  after  the  hard  work 
incidental  to  her  duties.  She  called  at  the  dispensary  during  the 
past  summer  (1879)  to  consult  me  regarding  a  pain  in  the  back, 
which  proved  to  be  a  localized  hyper£esthesia — a  condition  which 
did  not  exist  during  the  previous  treatment  of  her  case.  She  told 
me  that  her  limbs  were  equally  strong,  and  that  the  ailing  hip  had 
given  her  no  pain  or  uneasiness  for  many  months. 

Rcina7-ks. — The  symptoms  in  this  case  were  well  calcu- 
lated to  deceive,  and  had  the  patient  been  "  coached  "   by 


24  NE  WTON  M.   SHAFFER. 

an  expert  they  could  scarcely  have  been  more  closely  simu- 
lated ;  and  yet  this  girl  had  never  seen  a  case  of  hip-joint 
disease,  and  knew  no  more  of  its  symptoms  than  does  a 
child  of  three  years.  If  further  confirmation  was  needed  to 
sustain  the  correctness  of  the  diagnosis,  note  the  effect  of 
the  extension  apparatus :  "  Relieved  of  pain,  and  walks 
very  nicely  with  splint," — its  almost  invariable  effect  in  true, 
chronic  coxitis.  There  was  no  disturbance  of  uterine  func- 
tion, no  symptoms  of  spinal  irritation,  no  hysterical  convul- 
sions, no  particular  emotional  disturbance ;  but  there  was 
an  indescribable  something  about  the  patient  as  she  walked 
into  the  dispensary  with  the  apparatus  applied — as  I  first 
saw  her — which  suggested  neuromimesis.  There  was  the 
absence  of  the  relation  of  cause  and  effect  regarding  her 
attitude  and  other  expressions  of  her  condition  :  a  volun- 
tary, and  therefore  irregular,  effort  to  accommodate  the  one 
to  the  other,  characteristic  of  the  false  as  distinguished 
from  the  real  disease,  and  the  result  of  the  examination 
fully  confirmed  my  suspicion.  The  differential  diagnosis 
turned  principally  on  two  points,  viz. :  the  absence  of  the 
expressive  atrophy  of  the  thigh  muscles  and  the  absence  of 
i\\Q.  persistent  character  of  the  reflex  muscular  spasm,  which 
is  an  invariable  symptom  of  chronic  osteitis  of  the  hip- 
joint.  It  was  in  this  case  that  I  first  tested  the  thigh  mus- 
cles with  the  faradic  current,  and  found,  as  I  have  previously 
stated,  a  normal  contractility. 

It  is  worth  while  to  call  attention  to  the  fact  that  in  some 
cases  of  neuromimesis,  as  in  this,  the  patient  will  express 
himself  as  greatly,  perhaps  almost  wholly  relieved  after  ap- 
paratus is  applied  ;  others  wear  their  pads  and  straps  so 
very  tight  that  excoriations  result,  and  insist  that  the  appli- 
ances fail  to  give  them  comfort  unless  so  worn — ignoring 
excoriations  and  other  inconveniences  which,  in  the  true 
disease,  often  cause  great  uneasiness. 


H  YS  TERICA  L  JOIN  T  A  FFE  C  TIONS.  2  5 

In  other  cases  the  apparatus  is  soon  discarded,  having 
produced  no  other  effect  than  the  trouble  incident  to  its 
use,  leaving  the  patient,  apparently,  much  worse  than  when 
it  was  put  on.  I  draw  no  distinction  as  to  which  class  re- 
covers the  more  quickly  ;  the  one  just  detailed  made  an 
exceptionally  rapid  recovery.  I  have  now  a  case  under  ob- 
servation, which  was  referred  to  by  my  friend,  Dr.  T.  G. 
Thomas,  where  everything  which  could  be  suggested  by 
the  most  eminent  medical  talent  in  the  city  was  carried  out 
in  the  treatment  of  a  recognized  hysterical  paralysis  of  the 
right  lower  extremity,  with  only  partial  success.  With  ap- 
paratus the  patient  is  now  comfortable,  and  walks  much 
better  than  before  its  use ;  but  the  question  of  complete 
recovery  is  one  which  the  future  only  can  decide. 

Case  5. — Miss  E.  O.,  aged  20,  residence,  Greenpoint,  New 
York,  applied  for  treatment  at  Orthopaedic  Dispensary,  September 
29,  1S75. 

The  patient's  parents  are  living  and  in  good  health  ;  has  two 
brothers  and  two  sisters,  all  in  good  health,  except  one  sister 
younger  than  herself,  who  has  suffered  from  chronic,  suppura- 
tive hip  disease  for  eight  years,  and  who  has  been  under  the  im- 
mediate care  of  the  dispensary  for  several  years.  There  is, 
apparently,  a  good  family  history  with  this  exception,  and  no  dis- 
ease of  the  nervous  system  is  known  in  previous  generations. 

The  patient  has  always  been  "  a  delicate  girl."  Menses  first 
appeared  at  14 — very  irregularly  at  first,  but  recently  a  great  im- 
provement has  taken  place  in  this  respect.  Is  in  apparently  good 
physical  condition,  though  somewhat  pale. 

Last  winter  (1874),  she  fell  while  stepping  from  a  street  car,  and 
''hurt  her  hip,"  beside  "cutting  her  elbow  and  knee."  The  pa- 
tient walked  home,  however,  with  a  decided  limp.  Soon  after  she 
"wrenched  her  hip"  badly  while  rolling  a  barrel  of  flour.  This 
last  accident  proved  more  serious  than  the  former,  the  patient  be- 
ing unable  to  walk  after  the  second  injury  to  the  joint.  She  was 
carried  into  the  house  and  placed  in  bed,  from  which  she  did  not 
move  for  three  days.  During  this  time  she  suffered  much  pain  in 
and  about  the  hip,  and  after  again  assuming  the  upright  position 
she  walked  with  "  a  bad  limp,"  and  required  assistance  in  goin 


26  NEW  TON  31.   SHAFFER. 

up  and  down  stairs  for  several  weeks.  In  the  following  spring 
(March)  "  pain  in  the  back"  appeared  as  an  urgent  symptom,  the 
pain  being  located  over  sacro-iliac  junction.  The  lameness  and 
the  pain  were  treated  at  home  without  success.  In  April  she  was 
seized  with  what  the  family  physician  called  "  neuralgia  of  the 
spine,"  and  soon  after  hysterical  convulsions  appeared.  Consulta- 
tions were  held,  and  "heart  disease"  and  "tumor  in  the  groin" 
were  diagnosed.  In  this  condition  she  went  to  Connecticut 
to  visit  a  frient.  While  there  she  again  "sprained  her  hip." 
This  third  injury  to  the  hip  joint  was  followed  by  an  in- 
crease of  the  limping,  pain  in  the  back,  hip  and  knee,  and  very 
restless  nights.  She  returned  to  New  York  on  September  25th, 
the  symptoms  being  much  aggravated  by  the  journey.  The 
pain  in  the  knee  became  worse,  sleep  was  very  irregular  and 
greatly  disturbed,  "  the  limb  began  to  draw  up,"  and  the  knee  rest- 
ed against  the  opposite  thigh.  Crutches  were  obtained,  and  with 
their  use  and  the  assistance  of  her  mother  the  patient  presented 
herself  for  examination. 

I  w^as  about  leaving  the  dispensary  when  the  patient  ap- 
peared. Having  an  engagement,  I  did  not  stop  to  make  a 
careful  examination,  but  taking  into  consideration  her 
marked  expressions  of  pain,  both  facial  and  oral,  as  I  moved 
the  limb  while  the  patient  stood  before  me  upon  crutches, 
her  attitude,  the  rapidly  repeated  history  of  traumatism, 
and  the  apparent  extreme  disability  and  muscular  rigidity 
of  the  hip  joint  and  especially  remembering  that  the  pa- 
tient's sister  was  under  my  care  for  morbus  coxarius,  I  di- 
rected the  house  surgeon,  Dr.  George  B,  Packard,  to  apply 
a  weight  and  pulley  if  manual  traction  should  afford  relief. 
The  examination  of  the  house  surgeon  is  thus  recorded : 

"  Patient  pale  and  with  anxious  countenance  ;  limps  very  badly  ; 
a  great  deal  of  hypersesthesia  of  back,  especially  in  lumbar  re- 
gion ;  vertebral  column  very  flexible  ;  no  prominence  visible  ; 
great  tenderness  in  inguinal  region  ;  excruciating  pain  and  ap- 
parent reflex  contraction  on  movement  of  joint  ;  flexion  and  ad- 
duction of  thigh  ;  flattening  of  natis  ;  gluteo-femoral  crease  lower 
and  larger.  Traction  relieves  pain.  Patient  entered  ward,  and 
weight  and  pulley  applied." 


HYSTERICAL  JOINT  AFFECTIONS.  2/ 

October  ist. — "  Relieved  a  little,  but  does  not  sleep  well.  Order- 
ed morph.  sulph.  gr.  Y^^  at  night.  Does  not  get  much  relief  from 
pulley  ;  complains  of  pain  in  each  hip.  The  symptoms  are  those 
of  hysterical  hip  disease,  and  a  diagnosis  to  this  effect  was  made 
by  the  surgeon-in-charge." 

October  8th, — "  Ordered  a  few  drops  of  tint,  of  cinchona  bark  as 
a,  substitute  for  the  ]4,  gr.  dose  of  morphine.  The  effect  was  the 
same  as  though  morphine  had  been  given.  The  condition  is  un- 
mistakably a  hysterical  one,  and  patient  was  ordered  to  get  out  of 
bed  and  to  attempt  to  walk.  She  walked  with  great  difficulty, 
using  a  chair  in  place  of  crutches.  The  hip  symptoms  have  sub- 
sided entirely,  and  are  now  centered  in  the  knee  joint,  which  has 
bqen  held  in  extreme  extension  by  the  weight  and  pulley." 

October  20th. — "  Discharged  in  the  following  condition  :  Hip 
symptoms  wholly  removed,  but  the  knee  is  held  firmly  fixed  in  the 
position  it  may  happen  to  assume  after  manipulation.  Consider- 
able pain  in  the  knee,  and  patient  walking  very  badly." 

December  2,  1876. — "  The  mother  called  to-day  to  report,  and 
says  she  '  is  sure  the  doctors  dislocated  the  knee  joint  while  the 
patient  was  in  the  ward.'  This  'dislocation'  was  reduced  in 
the  following  manner  :  'While  rubbing  the  joint  with  a  liniment, 
something  suddenly  snapped,  and  the  following  morning  the  pa- 
tient could  walk  as  well  as  ever  before.'  " 

April  10,  1877. — "The  patient  called  at  the  dispensary  to-day 
with  her  sister's  hip  splint,  which  needed  repairs.  She  walks  per- 
fectly well.  Sleeps  well  '  with  valerian  once  in  a  while.'  Has 
pain  in  hip  and  knee  during  easterly  storms  and  after  very  long 
walks.     No  difference  in  size  or  length  of  limbs." 

Remarks. — All  the  symptoms  in  this  case  were  very  ur- 
gent, and  I  have  never  seen  a  closer  imitation  of  the  real 
disease.  These  symptoms  were  developed  in  a  tolerably 
well-nourished  girl,  who  had  been  the  personal  attendant  of 
her  afiflicted  sister  for  several  years.  This  sister  had  passed 
through  all  the  stages  of  a  chronic,  suppurative  coxitis.  The 
mimicry  in  this  case  is  undoubted.  The  dread  of  the  disease, 
of  which  she  daily  saw  a  very  painful  example,  was  suffi- 
cient, in  her  extremely  sensitive  condition,  to  develop  the 
train  of  symptoms  described,  and  which,  at  my  first  and  su- 
perficial examination,  deceived  me.      But  when  1  again  ex- 


28  NEWTON  M.   SHAFFER. 

amined  the  patient,  after  the  weight  and  pulley  had  been 
applied  for  two  days,  I  found  much  the  same  condition  of 
affairs  as  has  been  described  in  Case  4.  When  the  first  at- 
tempt to  flex  the  thigh  was  made,  the  patient  being  in  the 
supine  position,  an  exaggerated  expression  of  pain  followed 
that  would  be  difficult  to  describe,  and  the  pelvis  moved 
with  the  thigh  as  though  an  actual  anchylosis  existed  at  the 
hip  joint.  Next  ,1  held  the  pelvis  firmly,  and  strove  to 
overcome  the  flexion.  The  pelvis  tilted  forward,  and  the 
tubera  ischii,  resting  on  the  mattress  underneath,  became  the 
fulcra  by  which  the  lumbo-dorsal  spine  was  alternately 
lordosed  or  kyphosed.  Abduction  of  the  thigh  was  next 
tested.  But  the  pelvis  moved  with  the  femur  upon  the  op- 
posite acetabulum  at  the  expense  of  the  vertebral  column. 
But  I  became  convinced  from  various  over-expressions  of 
pain  and  exaggerated  statements  as  to  the  effect  of  some 
simple  tests,  coupled  with  the  history  of  hysterical  convul- 
sions, that  a  neuromimesis  of  hip  disease  was  present. 
While  the  patient  was  looking  in  another  direction,  I  made 
a  persistent,  but  not  forcible  flexion,  and  after  a  few  seconds 
of  determined  resistance  the  joint  suddenly  yielded.  So  it 
proved  regarding  the  other  movements,  until,  after  a  time, 
free  passive  motion  of  the  articulation  was  permitted  with- 
out pain. 

The  patient  was  in  bed.  Buck's  extension  was  applied  to 
the  limb,  and  the  question  arose :  What  shall  be  done  ? 
It  was  deemed  best  to  continue  the  traction  for  a  few  days. 
This  was  done,  and  the  patient  then  was  pcj'initted  to  get 
up.  As  mentioned  in  the  notes,  all  the  hip  symptoms  dis- 
appeared under  this  treatment,  and  the  trouble  concentrated 
about  the  knee  joint  ;  and  this  complication  did  not  yield 
prior  to  the  discharge  of  the  patient.  The  manner  in  which 
recovery  was  effected  is  very  suggestive  of  the  methods 
employed  by  the  professional  "  bone-setters." 


HYSTERICAL  JOINT  AFFECTIONS.  29 

Case  6.  Charlotte  K.,  aged  12  :  admitted  to  St.  Luke's  Hos- 
pital, May  13,  1879. 

A  portion  of  my  own  notes  of  this  case  have  been  mis- 
laid and  I  am  indebted  to  my  friend,  Dr.  Robert  Abbe  for 
the  following  memoranda  made  by  him  when  the  patient 
entered  the  hospital. 

Patient  enters  hospital  in  excellent  general -condition  but  com- 
plaining of  much  pain  about  the  right  hip  on  walking  or  sitting 
down.  She  has  a  marked  limp  and  drops  on  that  side  when 
walking  ;  she  gives  a  history  of  having  been  injured  on  that  side 
eight  years  ago,  with  pains  and  limping  ever  since.  On  exam- 
ination there  is  : 

1.  Shortening  three-eighths  of  an  inch  by  measurement  of 
limbs. 

2.  Atrophy  of  solid  tissues,  the  right  thigh  and  calf  being  one- 
fourth  inch  less  in  circumference  than  the  left. 

3.  The  natal  fold  on  the  right  side  is  higher  and  deeper — the 
buttock  slightly  flattened. 

4.  The  inguinal  fold  is  drawn  up  on  the  right  side  and  the 
genital  fissure  considerably  drawn  to  the  affected  side. 

5.  Pain  about  the  inguinal  region  and  iliac  fossa  ;  likewise 
pain  in  pinching  up  the  skin  anywhere  on  either  thigh  or  leg. 

6.  Some  adduction  and  a  little  flexion  of  thigh  on  abdomen. 

7.  The  patient  refuses  to  flex  thigh  on  abdomen  when  lying 
down,  or  to  allow  much  flexion  of  it. 

8.  There  is  rigidity  of  all  the  muscles  of  the  affected  thigh. 

Points  on  which  an  exclusive  diagnosis  was  made. 

1.  The  emotional  element  in  the  child  ;  easily  affected  to 
tears,  without  pain.  She  seemed  also  very  conscious  of  observa- 
tion and  suspicious  of  it. 

2.  The  rigidity  of  muscles  of  thigh  is  variable,  as  when  atten- 
tion is  directed  thereto  or  diverted  therefrom,  etc. 

3.  The  flexion  of  thigh  which  occurs  when  patient  sits  in  a 
chair  cannot  be  obtained  when  she  lies  down. 

4.  Patient  can  put  on  her  own  shoes  and  stockings. 

5.  She  attributes  disease  to  and  dates  back  her  trouble  from  an 
injury  eight  years  ago. 

6.  There  is  more  or  less  hyperaesthetic  pain  at  most  any  point 
of  opposite  leg,  or  any  part  of  body  when  pinched  or  touched. 


30  NEWTON  M.   SHAFFER. 

7.  Uniform  temperature  ;  no  evidence  of  suppuration  ;  good 
appetite  ;  good  general  condition. 

8.  Psoas  muscle  was  not  involved  in  the  contraction. 

In  a  letter  recently  received  from  Dr.  Abbe,  he  also  says: 

"  The  child,  when  not  conscious  of  observation  was  occasional- 
ly seen  when  playing  with  other  children,  to  jump  down  from 
buttress  of  the  front  steps  of  the  hospital — a  distance  of  three 
feet,  and  to  run  off  without  evidence  of  pain.  She  was  also,  on 
one  occasion,  taken  off  her  guard  by  an  offer  of  money  with  which 
to  buy  peanuts  from  a  passing  vendor  and  momentarily  developed 
an  unexpected  freedom  of  action  about  the  hip  joint." 

This  case  came  into  my  service  at  the  hospital  with  a 
diagnosis  of  hip  joint  disease,  and  Dr.  Abbe  has  described 
symptoms  upon  which  such  a  diagnosis  might  easily  be 
made,  but  the  condition  of  the  patient  and  the  elements  of 
the  exclusive  diagnosis  are  so  plainly  stated  in  the  notes 
that  extended  comment  seems  unnecessary.  In  this  as  in 
the  preceding  case,  the  extremely  variable  character  of  the 
muscular  contraction  was  the  turning  point  in  diagnosis ;  a 
wide  difference  existed  between  the  symptoms  developed 
at  the  formal  examination  and  those  shown  by  the  patient 
when  she  thought  herself  unobserved. 

I  may  mention  one  other  point  which  would  be  of  value 
were  the  elements  of  diagnosis  more  confusing;  i.e.,  the 
atrophy.  It  was  the  same  at  both  leg  and  thigh.  In  true 
joint  disease  of  several  years'  standing,  the  atrophy  of  the 
thigh  is  far  in  excess  of  that  of  the  leg.  I  have  made  and 
recorded  several  hundred  observations  on  this  point  and 
find  such  to  be  uniformly  the  case.  The  shortening  of 
three-eights  of  an  inch  was  undoubtedly  congenital.  This 
patient  recovered  under  the  treatment  pursued  in  the  other 
cases  reported,  and  left  the  hospital  in  a  few  weeks. 

Case  7.     D.  P.,  ?et.  10.     Residence,  N.  Y.  State. 

This   patient   applied   to   me  on   September   to,  1876,  suffering 


H  YS  r ERIC  A  L  JOINT  A  FFE  C  TIONS.  3 1 

from  all  the  important  and  many  of  the  urgent  symptoms  of  hip 
disease — left  side.  The  hereditary  history,  as  related  by  her 
mother,  was  not  very  satisfactory,  as  nothing  definite  could  be 
learned,  other  than  the  fact  that  the  child's  father  was  dead,  and 
that  "  all  the  rest  of  the  family  were  healthy." 

The  symptoms  from  which  the  patient  suffered  had  been  of  in- 
sidious growth.  She  first  commenced  to  limp,  shortly  after  an  in- 
jury to  the  hip.  The  limp  had  been  followed  by  pain,  though, 
the  mother  states  that  the  pain  followed  so  soon,  as  to  be  almost 
coincidental  with  the  limping.  The  pain  was  in  the  thigh,  knee 
and  hip,  the  patient  passed  through  some  sleepless  nights,  and 
gradually  the  limb  had  become  "  very  weak  and  deformed."  The 
limp  and  pain  became  so  much  worse  that  crutches  were  used. 
The  patient  used  these  crutches  as  she  came  into  my  office — with 
a  diagnosis  of  hip  disease,  and  a  letter  of  introduction  from  a 
prominent  surgeon  of  one  of  the   Hudson   River  counties. 

It  was  with  great  difficulty  that  the  patient  was  pursuaded  to 
lie  down  upon  a  lounge  for  examination.  After  many  efforts 
and  a  great  many  suggestions  from  the  mother,  the  patient  was 
finally  placed  in  the  supine  position,  the  mother,  in  the  mean 
time,  making  what  seemed  to  be  manual  traction  with  a  degree 
of  force  that  indicated  long  practice.  The  patient,  all  this 
time,  was  shrieking  with  pain,  and  grasping  the  furniture  near 
at  hand,  apparently  as  a  means  of  counter-traction.  I  imagined 
that  the  case  was  one  of  chronic  osteitis  of  the  hip  joint,  in  the 
stage  of  exacerbation.  After  much  persuasion  I,  at  last,  induced 
the  mother  to  permit  me  to  make  the  traction  and  control  the 
limb.  I  then  commenced  to  gently  test  the  condition  of  the 
joint,  as  regards  motion.  While  manipulating  in  the  mildest 
manner,  I  was  startled  by  an  urgent  cry  from  the  patient,  and  an 
imperative  command,  "  hold  it  tighter,"  two  or  three  times  re- 
peated. I  was  already  making  all  the  traction  possible,  and 
naturally  asked  an  explanation.  The  mother  hurriedly  said  "  you 
don't  squeeze  the  ankle  tightly  enough."  This  threw  a  new 
light  on  the  symptoms.  Desisting  wholly  from  all  efforts  at  trac- 
tion, I  merely  compressed  the  ankle  joint  with  all  my  power. 
While  doing  this  I  could  place  the  thigh  in  any  position,  and 
could  even  press  the  articular  surfaces  together  without  resist- 
ance or  complaint. 

Still  "  squeezing  the  ankle,"  I  was  able  to  get  the  patient  in  the 
upright  position  with  little  or  no  trouble.  Without  any  support 
but  that  afforded  by  her  crutches,  the  thigh  became  flexed  and  ad- 


32  NEWTON  M.   SHAFFER. 

ducted.  The  whole  limb  was  visibly,  though  not  markedly  atro- 
phied. There  were  various  hyperaesthetic  areas  on  the  affected 
limb — principally  on  the  inner  aspect  of  the  thigh — and  over  the 
crest  of  the  ilium.  Pain  was  produced  by  pressure  through  the 
trochanters,  by  crowding  the  sacro-iliac  surfaces  together,  and  by 
digital  compression  in  the  inguinal  region.  The  patient  stated 
absolutely  that  she  could  not  walk  without  support.  There  was 
normal  faradic  contractility  of  the  .leg  and  thigh  muscles. 

I  informed  the  mother  that  her  child  did  not  have  hip 
disease — and  advised  the  same  course  of  treatment  that  had 
been  successfully  pursued  in  other  cases.  My  diagnosis  was 
not  well  received.  The  mother  openly  declared  that  she 
preferred  Dr. 's  opinion  to  my  own. 

I  had  almost  forgotten  about  the  case  when,  one  day,  in 
passing  through  my  ward  at  St.  Luke's,  I  again  met  my 
former  patient,  still  upon  crutches,  and  still  suffering  from 
''  hip  disease," — under  which  diagnosis  she  entered  the  hos- 
pital. It  seems  that  the  mother  o^  the  patient  had  wholly 
disregaded  my  advice,  and  had  consulted  a  prominent 
surgeon  of  this  city,  who,  after  a  careful  examination,  had 
diagonized  coxitis,  and  had  said  I  "  had  made  a  great 
error."  The  especial  attention  of  the  house  staff  was  called 
to  the  patient  and  my  friend,  Dr.  G.  A.  Spalding  made  the 
following  notes  of  the  case,  which  he  has  kindly  given  me. 

1.  Patient  entered  hospital  on  October  30,  1876,  using  crutches, 
and  refusing  to  stand  upon,  or  use  her  left  limb,  in  any  way. 

2.  Thigh  flexed  and  adducted.  The  attitude  and  position  of 
limb  were  characteristic  of  hip  disease. 

3.  Very  marked  expression  of  pain  on  passive  motion  of  joint 
— principally  at  the  knee. 

4.  Joint  motion  limited  in  every  direction  at  first.  It  became 
almost  normal  when  persistent  effort  was  made  while  patient's  at- 
tention was  diverted.     Apparent  atrophy  of  thigh  and  leg  muscles. 

5.  Patient  very  restless  at  night.  She  had  used  morphine 
prior  to  entrance  to  hospital. 

6.  When  patient  was  under  observation  she  complained  much 
more  than  when  she  imagined  herself  unobserved. 


HYSTERICAL  JOINT  AFFECTIONS.  33 

7.  Traction  relieved pain^  and  apparently  rendered  patient  more 
comfortable. 

The  peculiarity  manifested  when  I  first  examined  the 
limb,  viz.:  the  preference  for  a  squeezing  sensation  at  the 
ankle  had  become  greatly  modified.  The  patient  was  now 
relieved  by  direct  traction  only. 

The  treatment  pursued  consisted  in  the  removal  of  the 
crutches,  passive  movements,  with  cod  liver  oil  and  ferrugi- 
nous tonics.  She  improved  very  rapidly  and  on  December 
20,  1876,  she  left  the  hospital  without  any  evidences  of 
hip  disease.  The  subsequent  career  of  this  patient  is  thus 
described  by  Dr.  Spalding  in  a  letter  to  me : 

"On  Feb.  19,  1877,  about  two  months  after  her  discharge,  her 
mother  again  presented  the  patient  for  admission  to  the  hospital, 
giving  the  following  history  :  A  few  weeks  previous  she  had  been 
seized  with  convulsions.  These  convulsions,  the  mother  stated,  were 
becoming  more  and  more  frequent  and  alarming — as  many  as  three 
or  four  occurring  in  twenty-four  hours.  As  the  mother  gave  this  his- 
■  tory,  she  was  occupied  in  unrolling  a  large  bundle,  which  proved  to 
be  a  blanket.  This  she  spread  carefully  upon  the  floor,  remarking 
that  the  hour  for  one  of  these  attacks  had  arrived,  and  that  it  was 
her  custom  to  put  the  blanket  down  as  a  protective.  Precisely  at 
II  o'clock  A.  M.  the  patient  composed  herself  comfortably  upon 
the  blanket,  and  passed  into  one  of  the  most  characteristic  hysteri- 
cal convulsions  I  have  ever  witnessed.  The  subsequent  history  is 
very  brief  and  most  satisfactory.  The  usual  remedies  lessened 
the  frequency  and  shortened  the  duration  of  these  attacks.  But 
an  absolute  cure  was  not  affected  until  later.  I  chanced  to  be  in 
the  ward  one  day  at  the  time  the  patient  was  seized  with  a  convul- 
sion, and  happening  to  see  a  siphon  of  carbonic  acid  water,  I 
picked  it  up  and  holding  the  young  girl  firmly  by  the  back  hair  I 
discharged  the  contents  of  the  siphon  down  her  throat.  Her  con- 
vulsive movements  were  instantly  checked,  and  she  promised  to 
avoid  all  such  conduct  in  the  future.  She  kept  her  word,  and  in 
a  few  weeks  was  discharged  from  the  hospital.  During  all  this 
time  the  patient  had  no  recurrence  of  the  hip  joint  manifesta- 
tions." 

Remarks. — The  hysterical  diathesis  was  well  demonstrated 


34  NE  WTON  M.  SHAFFER. 

in  this  case,  as  Dr.  Spalding's  experience  proves  ;  and  my 
own  experience  shows,  as  I  have  remarked  in  other  cases, 
that  a  diagnosis  of  "  hysteria,"  be  it  qualified  by  ever  so 
many  Greek  names,  is  very  apt  to  produce  a  not  very  pleas- 
ant impression,  so  far  as  the  patient  and  her  friends  are  con- 
cerned. 

We  observe  also  in  this  case  the  change  in  the  symp- 
toms, as  relating  to  traction  of  the  joint.  When  I  first  ex- 
amined the  patient,  I  explained  to  the  mother,  in  presence 
of  the  child,  that  in  true  joint  disease  traction  afforded  re- 
lief, and  that  simply  "  squeezing  of  the  limb  "  would  not 
produce  any  effect  upon  true  joint  symptoms.  When  the 
patient  entered  St.  Luke's  she  was  fully  prepared  upon 
this  point,  and  I  have  no  doubt  that  this  information  assist- 
ed in  deceiving  the  next  examiner. 

We  are  assisted  in  our  study  of  knee  joint  lesions  by 
many  favoring  circumstances.  We  can  detect  by  inspection 
alone  any  considerable  change  in  the  outline  of  the  ai'tic- 
ulation.  We  can  discover,  oftentimes  without  the  ther- 
mometer, a  rise  of  temperature,  due  to  intra-articular 
changes.  Palpation  is  of  great  service,  and  the  appear- 
ance of  the  superficial  tissues  is  frequently  of  material  as- 
sistance. But  in  considering  the  differential  diagnosis  of 
hip  joint  lesions  in  the  first  stage,  we  cannot  rely  with 
the  same  certainty  upon  any  one  of  these  diagnostic  aids. 
Inspection  shows  us  a  flattened  natis,  a  deformed  position, 
an  altered  gluteo-femoral  crease,  etc.,  all  of  which  may  arise 
from  a  variety  of  causes.  The  surface  thermometer  is  rare- 
ly of  service.  The  joint  is  too  remote  from  the  surface 
to  make  palpation  available,  in  the  first  stage  of  the  dis- 
ease, in  the  great  majority  of  cases,  and  the  appearance  of 
the  superficial  tissues  is  not  of  special  diagnostic  value. 
Our  means  of  objective  diagnosis  are  therefore  limited  at 
the  hip,  and  we  are  obliged  to  depend  upon  a  closer  anal- 
ysis of  the  symptoms,  especially  the  subjective. 


H  YS TERICA L  JOINT  A FFE C TIONS.  3  5 

Bearing  these  facts  in  mind,  and  recalling  the  essential 
points  developed  in  our  study  of  the  true  and  false  lesions 
of  the  knee,  especially  as  applied  to  chronic  osteitis  and 
neuromimesis,  we  may  summarize  our  observations  upon 
these  same  points  as  applied  to  the  hip  as  follows : 

In  chronic  osteitis  of  the  hip"^  there  exists,  among  others, 
the  following  symptoms : 

1.  A  limp,  which  forms  in  the  large  percentage  of  cases 
the  first  symptom  noticed, — a  limp  which  is  not  expressive 
of  fatigue, — which  is  more  apparent  after  rest  than  after  ex- 
ercise, and  which  usually  increases  until  the  patient  is  unable 
to  bear  any  weight  upon  the  affected  joint. 

2.  Paiji.  This  symptom  rarely  antedates  the  limp,  but 
may  appear  simultaneously.  Generally  it  follows  the  limp 
after  many  weeks,  sometimes  months.  The  pain  is  usually 
referred  to  the  knee,  and  is  very  frequently  described  as 
presenting  at  some  point  remote  from  the  hip. 

3.  A  state  of  apprehensioji  regarding  joint  movements, 
difificult  to  describe.  This  apprehensive  state  always  at- 
tends the  pain,  and  frequently  antedates  its  oral  expression. 
It  is  almost  invariably  developed  by  passive  motion  if  push- 
ed beyond  the  point  of  muscular  resistance,  and  is  plainly 
demonstrated  by  some  particular  form  of  forcible  move- 
ment— by  concussion  in  some,  by  quickly  rotating  the  thigh 
in  others,  etc. 

4.  Muscular  spasm.  This  exists  always  as  a  symptom  of 
chronic  osteitis  of  the  hip  joint,  though  its  existence  might 
easily  be  overlooked  in  the  early  stage  of  the  disease  by 
a  careless  observer.  In  this  early  stage,  the  one  most 
likely   to   be  confounded  with  neuromimesis,  this  spasm  of 

*  Chronic  synovitis  of  the  hip  joint,  is,  probably,  of  rare  occurrence,  and  is 
not  easily  diagnosed.  See  the  author's  Clinical  Lecture  on  the  "  Etiology  and 
Pathology  of  Chronic  Joint  Disease,"  pp.  18  and  34,  and  remarks  in  "  Pott's 
Disease,  Its  Pathology  and  Mechanical  Treatment,"  by  the  author,  p.  25  et  seq. 
See  also  remarks  by  V.  P.  Gibney,  M.D.,  in  Article,  "Dislocation  of  the  Hip  in 
Children." — Amer.  Jour.  Aled.  Sciences,  Oct.,  1879. 


36  NE  WTON  M.   SHAFFER. 

the  muscle  is  perceptible  in  the  extremes  of  flexion  and  ex- 
tension, and  it  is  especially  noticeable  when,  with  the  pa- 
tient in  the  prone  position  and  the  pelvis  firmly  held,  the 
flexed  leg  is  used  as  the  long  arm  of  a  lever  to  make  rota- 
tion of  the  thigh  outzvard.  This  muscular  spasm  increases, 
as  a  rule,  with  the  limp,  but  many  months,  or  even  years, 
may  pass  before  it  reaches  the  point  where  all  movement  of 
the  joint  is  arrested ;  and  cases  may  occur  where  the  spasm 
simulates  actual  anchylosis,  and  yet  there  may  be  a  very 
slight  limp  only,  and  no  oral  expression  of  pain. 

5,  A  progressive  muscular  atrophy  of  the  muscles  thus 
affected  as  shown,  as  has  been  already  mentioned,  by  com- 
parative measurements  and  the  electrical  test. 

It  will  not  be  necessary  to  mention  further  points.  They 
have  been  fully  considered  and  discussed  in  our  considera- 
tion of  the  knee  joint  conditions. 

In  the  neuromimesis  of  hip  disease  these  symptoms  pre- 
sent the  following  phases : 

1.  The  limp  is  variable  and  suggests  fatigue.  The  ex- 
pressive conservative  element  so  apparent  in  hip  disease  is 
lacking.  This  variable,  tired  limping  is,  as  a  rule,  much 
better  after  rest,  and  is  often  absent  in  the  morning  after 
sleep.  It  almost  invariably  follows  the  pain,  though  in 
Case  7  it  did  not. 

2.  Pain  is  usually  the  first  symptom,  and  it  is  found 
most  generally  in  the  immediate  region  of  the  joint — for 
example,  over  the  iliac  crest,  or  anterior  superior  spine. 
The  hyperaesthetic  character  of  this  pain  is  easily  demon- 
strated as  a  rule. 

3.  In  place  of  an  apprehensive  state,  in  response  to  the 
tests  applied,  will  be  found  a  series  of  symptoms  which  are 
erratic  and  inconstant. 

4.  A  condition  of  muscular  rigidity  often  exists,  but, 
unlike  the  true  muscular  spasm,  it  can,  in  most  cases,  be 
overcome  in  the  manner  before  stated. 


//  VS  TEKICA  L    JOIN  T  A  FFE  C  TIONS.  3  7 

5.  A  very  perceptible  degree  of  atrophy  may  exist,  such 
however,  as  would,  arise  from  inertia  only.  A  normal  elec- 
trical contractility  exists  in  all  the  muscles  of  the  thigh. 

The  conclusions  reached  in  our  study  of  the  knee  joint 
lesions  apply  with  equal  force  to  the  hip  joint,  local  tem- 
perature alone  excepted. 

Cases  sometimes  occur  where  actual  hip  joint  symptoms 
exist,  associated  with  undoubted  hysterical  manifestations. 
If  the  former  are  not  urgent,  and  the  latter  very  evident, 
the  difificulty  of  making  a  correct  diagnosis  is  very  great. 
The  danger  lies  in  ignoring  the  obscure,  but  real,  and  at- 
taching a  too  great  importance  to  the  false.  Such  a  case 
occurred  in  my  own  experience,  and  may  be  briefly  related. 

Case  8. — Miss  A.  S.,  a  young  lady  residing  in  Brooklyn,  of 
healthy  parentage  and  with  a  good  early  history,  passed  through 
the  ordinary  symptoms  of  the  first  stage  of  hip  disease,  and  came 
under  my  care  in  1875.  After  a  thorough  mechanical  treatment, 
covering  about  one  year,  all  the  symptoms  of  the  joint  lesion  sub- 
sided, and  in  consultation  with  the  family  physician,  Dr.  A.  W. 
Catlin,  it  was  decided  to  remove  the  splint.  This  was  done,  and 
the  patient  walked  without  any  limp,  except  that  which  would  be 
expected  from  the  disuse  and  confinement  of  the  limb. 

Soon  after  the  removal  of  the  splint,  however,  various  typical 
hysterical  symptoms  manifested  themselves,  and  hyperaesthetic 
areas  developed  in  various  portions  of  the  affected  limb,  and  espe- 
cially over  the  crest  of  the  iHum,  the  lumbar  spine,  the  sacro-iliac 
synchondrosis,  and  the  outer  portion  of  the  thigh.  There  were 
other  symptoms,  also  hysterical,  which  developed  at  the  knee 
joint,  and  the  emotional  condition  of  the  patient  became  very  ap- 
parent. All  of  these  pointed  to  a  neuromimetic  state.  While  in 
this  condition,  which  existed  for  some  weeks,  the  patient  began  to 
limp  slightly,  but  the  joint  motions  were,  as  before,  nearly  normal. 
The  involuntary  symptoms,  ^specially  the  nocturnal  ones,  were 
absent.  The  fact  that  there  was  a  slight  decrease  in  the  re- 
sistance to  joint  motion  as  the  limp  still  became  more  apparent, 
was  noted.  Still  the  limp  increased,  and  so  did  the  emotional 
symptoms.  The  limp  became  still  more  pronounced,  but  the 
other  joint  symptoms  did   not  keep  pace  with  the  debility  of  the 


38  NEWTON  M.  SHAFFER. 

limb,  while  the  hysterical  were  very  prominent.  This  condition 
remained  for  a  time,  when  the  apparent  urgency  of  some  of  the 
subjective  symptoms  led  me  to  suspect  that  the  emotional  symp- 
toms were  secondary  to  a  relapse  or  coincidental  with  it,  I  asked 
Dr.  E.  C.  Seguin  to  see  the  patient,  and  in  a  consultation,  at  which 
Dr.  A.  W.  Catlin  was  present,  it  was  decided  that  the  symptoms 
warranted  protection  to  the  joint.  Accordingly,  the  splint  was 
again  applied,  with  relief  to  all  the  symptoms,  the  hysterical  as 
well  as  those  which  were,  as  the  result  proved,  real,  for  the  forma- 
tion of  an  abscess  at  the  end  of  about  six  months  proved  the  cor- 
rectness of  Dr.  Seguin's  opinion.  The  case  has  done  well  ever 
since. 

The  insidious  progress  of  caries  sicca  of  the  articulations 
in  the  first  stage,  might  easily  suggest  neuromimesis,  or  some 
other  lesion  of  the  nervous  system,  as  it  did  in  the  case 
which  Esmarch  reports,  and  to  which  reference  has  already 
been  made.  In  caries  sicca  of  the  hip  joint  there  exists, 
when  the  disease  first  manifests  itself,  a  limp,  which  is  so 
slight  as  to  be  scarcely  noted, — very  slight  resistance  to  ex- 
treme joint  movements,  and  an  indefinite  expression  of 
pain ;  sometimes  no  oral  expression  of  pain  at  all.  After 
these  symptoms  have  existed  for  a  time,  they  may  wholly 
disappear  for  several  weeks.  When  they  again  return,  they 
are  a  little  worse,  and  generally  follow  some  slight  twist  or 
injury  to  the  joint.  A  total  remission  of  the  symptoms 
may  occur  several  times.  In  the  child  these  symptoms  are 
generally  referred  to  "  growing  pains,"  "  habit,"  etc.,  and  in 
the  adult  it  has  frequently  been  called  "  rheumatism,"  "  sci- 
atica," "hysteria,"  or  even  in  one  case  "malaria."  I  could 
relate  many  cases  of  this  character  did  space  permit.  I  can 
only  refer  in  these  general  terms  to  this,  the  serious  side  of 
the  question,  for  the  error  of^  diagnosing  a  joint  lesion, 
when  a  neuromimesis  exists,  is  as  nothing  compared  with 
the  evil  consequences,  the  deformity,  and  death,  which 
have  resulted  from  mistaking  a  progressive  and  serious  hip 
joint  lesion  for  "  sciatica  "  or  "  rheumatism." 


HYSTERICAL  JOINT  AFFECTIONS.  39 

I  have  seen  a  large  number  of  cases  of  simulated  dis- 
eases of  the  spine,  from  the  histories  of  which  I  select  the 
following  as  affording  the  most  instruction. 

Case  9. — Miss ,  aged  14  years,  residence,  New  York  State, 

was  seen  in  consultation  September  28,  1879. 

The  history  shows  that  the  patient  has  always  been  a  strong 
child.  She  is  one  of  six  children,  three  of  whom  are  now  living, 
one  having  died  in  early  infancy,  one  of  diphtheria,  and  a  third 
of  convulsions  following  measles.  Two  of  the  survivors  have  had 
convulsions.  The  patient  has  had  rheumatic  pains  at  various 
times  in  shoulders,  hips  and  knees,  which  were,  however,  of  but  a 
few  hours'  duration. 

The  hereditary  history  shows  phthisis  on  mother's  side,  one 
case  of  Pott's  disease  in  a  very  remote  branch  of  the  family,  and 
on  the  father's  side,  gout. 

There  was  no  trouble  with  the  patient's  back  until  five  years 
ago,  about  which  time,  riding  down  hill  in  a  little  wagon,  she  fell 
therefrom,  striking  the  lower  part  of  her  spine  upon  a  stone.  She 
was  able  to  walk,  however,  and  went  to  her  room.  A  "  black  and 
blue  "  spot  appeared  at  about  the  last  lumbar  vertebra  ;  she  was 
rubbed  with  liniments,  kept  quiet  for  a  few  days,  recovered  per- 
fectly and  remained  entirely  well  for  three  years.  Two  years 
ago,  when  about  twelve  years  of  age,  she  began  to  ride  on  horse- 
back, and  became  particularly  active  and  venturesome.  One  day 
after  a  long  ride  she  complained  of  her  back,  and  the  family  phy- 
sician was  summoned.  He  thought  "the  muscles  were  strained." 
Iodine  was  applied,  and  rest  prescribed  in  the  recumbent  position 
for  a  few  days.  Again  recovery  was  complete,  and  the  young  girl 
was  as  active  as  before,  except  that  the  horseback  rides  were  dis- 
continued for  about  three  months,  when  her  father  bought  for  her 
use  a  Shetland  pony.  He  "bolted  "  one  day  and  threw  the  girl 
over  his  head,  again  injuring  the  spine,  which  was  treated  as  be- 
fore with  iodine  and  rest.  But  on  this  occasion  other  symptoms 
supervened.  Practice  at  the  piano  tired  her  :  "  her  back  would 
ache  between  the  shoulders."  Practice  was  dropped.  She  be- 
came nervous  and  irritable  ;  was  very  tired  after  slight  exertion  ; 
desired  to  support  her  head  when  sitting  down,  and  the  spine 
became  tender  at  various  points.  In  this  state  of  affairs  the 
mother's  attention  was  called  to  a  case  of  Pott's  disease  in  a  dis- 


40  NE  WTON  M.   SHAFFER. 

tant  relative.  She  became  very  anxious  about  her  daughter,  who 
became  very  anxious  about  herself.  The  tender  spots  along  the 
spine  became  more  tender,  the  spinal  ache  was  more  marked. 
The  family  physician  admitted  he  was  in  doubt  as  to  the  condition 
of  the  spine,  and  the  case  was  sent  to  a  prominent  surgeon  of  this 
city  for  advice.  A  diagnosis  of  Pott's  disease  at  the  last  lumbar 
vertebra  was  made  ;  the  patient  was  placed  on  her  back  for  three 
weeks,  leeches  and  ice  were  applied  to  the  spine,  and  she  was 
then  encased  in  a  plaster  jacket,  after  suspension,  the  operation 
being  repeated  five  or  six  times  in  fifteen  months,  each  time  with 
relief.  After  the  removal  of  the  last  jacket,  however,  the  symp- 
toms became  worse,  and  the  patient,  naturally  enough,  objected 
to  its  renewal  during  the  Summer.  Her  mother,  in  the  meantime, 
had  kept  the  patient  very  quiet,  waiting  for  the  cooler  weather. 
When  the  patient  applied  to  me  for  advice,  the  mother  remarked 
that  her  daughter's  symptoms  were  worse  than  ever  before,  and  a 
fear  existed  that  a  relapse  had  occurred. 

Examination. — Several  hypersesthetic  spots  over  the  spine, 
chiefly  in  the  region  of  the  12th  dorsal  and  ist  lumbar  vertebrse  ; 
the  pain,  however,  when  present,  was  lower  down,  near  the  sacrum, 
and  it  had  always  been  of  a  superficial  character,  the  friction  of 
her  underclothing  at  the  tender  points  hurting  her  more  than  the 
surgeon  did  by  pressure  when  examining  the  parts.  There  was 
no  pain  or  history  of  pain  in  the  abdomen,  thighs  or  pelvis. 
Careful  examination  showed  normal  flexibility  of  the  spine  in  all 
directions,  and  there  was  no  muscular  resistance  when  the  psoas 
and  iliacus  were  put  upon  the  stretch,  with  patient  in  the  prone 
position  and  pelvis  firmly  held. 

The  spinal  deformity  showed  itself  principally  in  a  marked  ex- 
curvation,  a  slight  drooping  of  the  right  shoulder  and  some  lateral 
deviation.  Lower  extremities  of  equal  length.  All  traces  of  de- 
formity disappeared  in  the  prone  position. 

Patient  very  evidently  an  emotional  girl  of  active  mind  and  of 
tolerably  full  habit.  There  is  no  evidence  about  her — in  gait, 
attitude,  or  expression — indicative  of  Pott's  disease. 

A  diagnosis  of  neuromimesis  was  made,  and  the  patient  was 
told,  much  to  her  surprise,  that  no  apparatus  was  required.  She 
was  instructed  to  resume  her  equestrian  exercise,  and  to  do,  in 
short,  the  same  as  other  girls  of  her  age  in  such  matters.  A  letter 
recently  received  states  that  my  diagnosis  has  been  fully  con- 
firmed. 

It  seems  scarcely  necessary  to  comment  on  this  case,  and 


//  VS  TERICA  L  JOIN  T  A  FFE  C  TIONS.  4 1 

I  would  not  make  extended  comment  had  not  the  error  in 
diagnosis  been  committed  by  one  whose  opinion  in  such 
matters  is  generally  accepted  as  authoritative. 

1st.  It  has  been  stated  again  and  again  by  various 
writers  that  superficial  tenderness  over  the  vertebrae  is  in- 
dicative of  disease  of  the  spine — a  statement  which  other 
writers  contradict."'^  The  truth  is  that  this  localized  ten- 
derness does  exist  in  many  cases  of  true  vertebral  caries,  but 
it  is  frequently  developed  by  the  surgeon  at  his  examina- 
tion, and  has  no  real  connection  with  the  lesion.  There  is 
this  difference  between  the  tenderness  of  the  sub-cutaneous 
tissues  in  Pott's  disease  and  the  hyperaesthesia  of  neuro- 
mimesis.  In  the  former  it  is  rarely  made  the  subject  of 
complaint  by  the  patient,  and,  as  before  stated,  is  often  de- 
veloped by  the  surgeon  at  his  examination — while  in  the 
latter  condition  it  is  one  of  the  very  first  of  which  the  pa- 
tient speaks.  The  neuromimetic  fastens  on  any  abnormal 
sign — often  of  the  most  trivial  character  and  exaggerates 
its  importance  ;  the  victim  of  Pott's  disease  has  enough  to 
engage  his  attention  without  searching  for  superficial  tender 
spots. 

2d.     It  may  be  safely  asserted  that  perfectly  normal  move- 

*For  example  :  C.  B.  Radcliffe,  M.D.,  F.  R.  C.  P.,  in  Reynold's  System  of 
Medicine  (vol.  ii,  p.  718,  Article,  "Caries  of  the  Vertebral  Column,")  describes 
among  other  symptoms  of  this  disease  "  a  feeling  of  undue  heat,  or  even  burn- 
ing in  the  weak  and  painful  and  prominent  part,  which  is  not  felt  in  other  parts 
of  the  spine,  when  a  sponge  soaked  in  moderately  hot  water  is  passed  down  the 
spine — a  state  of  tenderness  on  pressure  or  concussion,  which  is  equally  restrict- 
ed to  the  same  weak  and  painful  and  prominent  part."  On  the  other  hand, 
Skey,  in  the  valuable  work  already  quoted,  (p.  56),  deals  thus  forcibly  with  these 
symptoms  :  "  Of  all  the  fallacies  that  cling  to  professional  practice,  of  all  the 
false  doctrines  which  the  pardonable  ignorance  of  a  former  generation  has  en- 
tailed on  modern  surgery,  none  can  surpass  that  which  affects  to  detect  a  carious 
disease  of  the  body  of  a  vertebra  by  drawing  the  fingers  down  the  spine." 
Again,  p.  55,  he  says  :  "  Fifty  or  sixty  years  ago,  a  provincial  surgeon  of  some 
note  recommended  the  application  of  a  hot  sponge  to  the  spine  with  a  view  to 
detect  disease  of  the  bodies  of  the  vertebra — there  was  some  excuse  for  ignor- 
ance then — there  is  none  now."  My  own  experience  leads  me  to  wish  that 
Skey's  statements  might  find  a  place  in  every  work  on  surgery.  The  frequency 
with  which  one  hears  the  remark  "  There  is  tenderness  over  the  vertebra," 
proves  that  faith  in  this  sympt&m  as  diagnostic  of  vertebral  caries  is  still  wide- 
spread. In  true  disease  it  has  no  significance  whatever  as  a  symptom  of  actual 
disease  of  the  bone. 


42  NE  IV TON  M.   SHAFFER. 

ments  of  the  spine  are  incompatible  with  the  existence  of 
Pott's  disease.  Such  fiexibiUty  existed  in  this  case,  and 
the  incorrect  diagnosis  could  only  be  made  by  giving  undue 
value  to  some  of  the  more  prominent  symptoms  presenting. 
Even  in  those  cases  of  neuromimesis  where  a  certain  degree 
of  spinal  rigidity  exists,  it  will  generally  be  found,  as  in  the 
cases  of  joint  disease  I  have  described,  that  a  persistent  ef- 
fort— not  a  forcible  one — will  overcome  it.  Nor  must  we 
mistake  the  acute  and  the  sub-acute  muscular  affections  for 
the  reflex  muscular  spasm  of  chronic  spondylitis.  I  have 
seen  some  cases,  especially  in  the  cervical  region  where  a 
differential  diagnosis  was  difficult,  but  in  a  great  majority 
of  neuromimetic  spines  you  will  find  muscular  lassitude 
rather  than  muscular  rigidity  :  inability  to  hold  the  spine 
erect  and  a  flexible  excurvation  rather  than  an  alert  mus- 
cular spasm  which  assists  in  protecting  the  diseased  parts 
from  concussion  and  aids  in  forming  the  compensatory, 
antero-posterior  curves  which  are  such  a  striking  feature  of 
caries  of  the  vertebrae  when  deformity  exists. 

Case  lo.  Miss  M.  A.,  set  .14.  Resides  in  N.Y.  State.  The  hered- 
itary history  of  this  patient  is  very  suggestive  :  two  of  her  grand- 
parents— one  on  either  side — had  paralysis  agitans  :  her  maternal 
grandmother  died  of  phthisis,  a  tendency  to  which  exists  in  this 
branch  of  the  family,  two  of  her  aunts  dying  therefrom,  and  her 
father's  family  are  subject  to  chorea.  Two  of  the  patient's  broth- 
ers have  died  of  ''brain  disease,"  and  a  sister  is  "very  nervous." 

As  a  child  the  patient  was  "very  quick  and  nervous,"  of  active 
mind,  and  had  no  serious  illness  up  to  the  age  of  eleven  years. 
She  seemed  prone  to  assume  responsibilities  beyond  her  years,  and 
sought  the  society  of  adults,  and  has  always  been  a  very  affection- 
ate and  emotional  girl.  Three  years  prior  to  my  examination  of 
the  case,  she  developed  symptoms  of  a  strongly  emotional  charac- 
ter which  affected  "  principally  the  back."  She  had  very  severe 
pains  in  the  dorsal  region  which  prevented  any  movement  of  this 
part  for  several  weeks.  This  was  followed  by  several  typical 
hysterical  symptoms.  While  recovering  from  this  condition,  her 
little  brother  removed  a  cliair  \\\)0x\  which  she  was  about  to  sit. 


HYSTERICAL  JOINT  AFFECTIONS.  43 

and  she  received  a  severe  concussion  of  the  spine.  The  symptoms 
of  trouble  in  the  back  now  became  very  urgent  :  any  movement 
of  the  vertebral  column  produced  pain  which,  at  times,  seemed  to 
encircle  the  body  and  frequently  found  its  most  marked  expres- 
sion in  the  abdomen  and^chest.  The  spine  began  to  "project 
backward  and  twist  sideways,"  and  any  jar  or  movement  increased 
the  pain  greatly.  The  recumbent  position  was  the  only  one  she 
could  tolerate,  and  she  had  kept  it  for  many  months  prior  to  my 
examination. 

Residing  400  miles  from  the  city,  she  was  brought  here  in  a  spe- 
cially prepared  compartment  of  a  sleeping  car,  and  was  conveyed 
to  her  hotel  on  cushions.  A  diagnosis  of  Pott's  disease  had  been 
made  by  the  family  physician,  and  strict  injunctions  had  been 
given  to  avoid  any  shock  or  jar  to  the  patient. 

On  examination  I  found  a  very  marked  excurvation  of  the  spine 
which,  however,  immediately  disappeared  in  the  prone  position, 
and  a  lateral  deviation  which  yielded  easily  to  manual  pressure. 
The  right  scapula  was  lower  and  more  prominent  than  the  left. 
There  were  various  points  of  tenderness  over  the  spinous  pro- 
cesses. Patient  was  unable  to  stand  alone.  Pain  existed  not  only 
posteriorly,  but  anteriorly  also — like  the  "  gastralgia  "  of  chronic 
spondylitis.  There  was  no  muscular  rigidity,  the  vertebral  column 
being  normally  flexible  in  all  directions.  There  was  no  contrac- 
tion of  the  psoas  muscles,  and  the  strictly  involuntary  symptoms 
which  accompany  true,  chronic  spondylitis  were  absent. 

Good  authorities  tell  us  that  pain  on  concussion  of  the 
spine,  especially  if  accompanied  by  pain  in  the  anterior  part 
of  the  thorax,  indicates  Pott's  disease,  and  it  is  certain  that 
in  typical  cases  these  symptoms  do  exist.  In  this  case 
they  formed  the  prominent  subjective  symptoms,  and  if 
taken  alone  would  be  very  apt  to  mislead.  There  was 
also  a  posterior  curvature  accompanied  by  lateral  deviation, 
which  latter  not  unfrequently  occurs  with  the  kyphos  of 
Pott's  disease.  But  the  kyphosis,  as  well  as  the  scoliosis, 
was  easily  removed,  and  instead  of  the  ever  present  muscu- 
lar rigidity  of  chronic  spondylitis,  was  found  a  normal  de- 
gree of  flexibility  of  the  spinal  column, 

A  diagnosis  of  neuromimesis  was  not  well  received.    The 


44  NEWTON  M.   SHAFFER. 

mother  of  the  patient  expressed  herself  as  disinclined  to 
accept  it,  so  positive  was  she  that  disease  existed.  After 
some  hesitation  it  was  finally  decided  to  follow  my  advice, 
■which  was  simply  to  ignore  the  pain  and  the  deformity  and 
to  accustom  the  patient  to  gradually  progressive  exercises. 
A  tonic  treatment  was  also  advised.  After  three  weeks  the 
patient  was  able  to  walk,  and  after  six  weeks  she  went  home 
suffering  little  or  no  pain.  Progress  after  her  return  was 
gratifying.     Recovery  was  complete  without  relapse. 

The  prominent  symptoms  of  chronic  spondylitis,  before 
the  appearance  of  the  characteristic  deformity,  may  be  briefly 
described  as  follows : 

1st.  Rigidity  of  the  vertebral  column  at  the  point  of  dis- 
ease, this  rigidity  being,  in  a  great  measure,  due  to  the  per- 
sistent reflex  muscular  spasm  which  has  already  been  de- 
scribed as  occuring  in  chronic  osteitis  of  the  knee  and  hip. 

2d.  Pain,  which,  like  the  pain  of  hip  or  knee-joint  disease, 
may  find  expression  orally,  or  give  evidence  of  its  existence 
by  the  apprehensive  state  already  referred  to.  When  the 
patient  locates  the  pain,  he  generally  describes  it  as  occur- 
ring in  the  region  to  which  the  spinal  nerves  of  the  diseased 
region  are  distributed.  The  pain  is  aggravated  by  any  sud- 
den motion  or  unexpected  jar.  The  same  kind  of  involun- 
tary symptoms,  the  nocturnal  cry,  etc.,  are  found  in  many 
cases  of  chronic  spondylitis  in  the  prodromal  stage.  In  some 
cases  the  disease  progresses  so  insidiously  that  the  actual 
deformity  is  the  first  symptom  noted  by  careless  observers. 
3d.  A  characteristic  attitude  and  gait,  which  are  imparted, 
partly  by  the  unremitting  reflex  spasm  (which  frequently 
obliterates  the  normal  curves  of  the  spine),  and  partly  by 
the  instinctive  effort  of  the  patient  to  avoid  concussion  or 
shock  to  the  diseased  surfaces. 

I  do  not  doubt  that  the  same  muscular  atrophy  occurs  in 
chronic   spondylitis  that   is  found  in   chronic  epiphysitis  of 


HYSTERICAL  JOINT  AFFECTIONS.  45 

the  knee  and  hip.  The  difficulty  of  demonstrating  it  in 
certain  muscles  is  apparent. 

In  neuromimesis  of  chronic  spondylitis  the  pain  is  gener- 
ally superficial,  and  is,  almost  always,  located  over  or  near 
the  spinous  processes;  it  is  sometimes  transient,  and  fre- 
quently changes  its  location  from  time  to  time.  In  Case  lo 
the  pain  appeared  on  the  anterior  surface  of  the  body,  but 
disappeared  under  the  curative  effect  of  exercise.  In  place 
of  the  reflex  muscular  spasm,  which  holds  the  vertebral 
column  so  rigidly  in  chronic  spondylitis,  and  which  pre- 
vents the  reduction  of  the  kyphos,  there  is  generally  found 
as  before  stated,  a  normal  degree  of  mobility  of  the  spinal 
column  under  properly  directed  manipulations.  There  is 
no  nocturnal  cry,  and  the  facial  expression  of  apprehen- 
sion, which  is  generally  marked  in  the  sufferer  from  Pott's 
disease,  is  so  far  wanting  that  the  expression  of  many  neu- 
romimetic  patients  is  even  merry. 

The  general  conclusions  reached  regarding  the  knee  joint 
are  as  applicable  to  the  spine  as  to  the  hip,  excepting  those, 
of  course,  which  pertain  exclusively  to  the  knee  as  a  dis- 
tinct articulation. 

If  we  recall  the  symptoms  presented  by  the  two  cases  of 
simulated  chronic  spondylitis  which  have  just  been  related, 
it  would  appear  that  the  danger  of  diagnosing  true  lateral 
curvature  of  the  spine  in  similar  cases  would  be  great. 
Each  of  these  patients  presented  a  distinct  lateral  spinal 
curvature,  accompanied  by  a  malposition  of  the  scapulae, 
and  these  symptoms  also  occur  in  true  scoliosis.  Indeed, 
cases  of  nervous  mimicry  of  true,  rotary,  lateral  curvature 
are  very  frequent,  and,  inasmuch  as  the  mimicry  is  often 
very  close,  we  should,  in  suspicious  cases,  be  very  careful  in 
our  analysis  of  the  symptoms  presented.  Fortunately,  the 
error  of  calling  a  hysterical  spine  a  true  lateral  curvature  is 
not  so  likely  to  be  followed  by  serious  results,  as  is  that  of 


46  NE  WTON  M.  SHAFFER. 

attributing  to  "  habit  "  or  "  hysteria  "  the  progressive  curva- 
ture of  true  scoliosis,  than  which  there  is  nothing  in  the 
whole  range  of  orthopaedic  surgery  more  insidious  in  its 
onset,  or,  when  it  is  fairly  established,  more  difificult  to 
arrest,  even  by  means  of  the  rejuvenated  gallows,  and  the 
much  lauded  plaster  of  Paris  bandage. 

The  almost  constant  association  of  emotional  symptoms, 
of  greater  or  less  intensity,  with  the  condition  of  true, 
rotary,  lateral  curvature,  has  led  many  to  suppose  that  the 
former  was,  in  some  unexplained  way,  a  factor  in  the  pro- 
duction of  the  formidable  conditions  met  with  in  the  latter. 
My  own  experience  leads  me  to  say,  while  recognizing  the 
fact  that  the  majority  of  cases  of  true  scoliosis  are  found 
in  emotional  girls,  and  that  mental  activity  is  its  frequent 
attendant,  that  I  am  no  more  prepared  to  admit  that  this 
emotional  state,  or  mental  activity  is  the  cause,  or  even  a 
cause  of  true  scoliosis  than  is  the  oft-noted  precocity  of 
strumous  children  a  factor  in  the  production  of  chronic  joint 
disease.  In  either  condition  the  emotional  state,  on  the 
one  hand,  or  the  precocity  on  the  other,  is  symptomatic  of 
the  general  condition. 

In  true  lateral  curvature  the  dorsal  curve  presents  to 
the  left  more  frequently  than  is  generally  supposed,  and  in 
my  own  experience  it  occurs  in  males  oftener  than  has 
been  stated.  Of  83  consecutive  cases,  occurring  at  the 
Orthopaedic  Dispensary  and  Hospital,  21,  or  34  per  cent, 
presented  a  left  dorsal  curvature,  and  18,  or  2']\  per  cent, 
were  males.  Adding  to  this  the  fact,  which  I  deduce  from 
the  examination  of  several  hundred  patients,  that  in  no 
two  cases  do  we  find  exactly  the  same  curves,  and  that  it 
is  exceptional,  in  a  group  of  cases,  to  see  the  same  number 
of  vertebrae  involved  in  the  primary  (dorsal)  curvature,  and 
we  reach  the  conclusion  that  we  must  look  for  our  primary 
muscular  factor,  in  the  production  of  true  lateral  curvature, 


HYSTERICAL  JOINT  AFFECTIONS.  47 

to  the,  strictly  speaking,  intervertebral  muscles,  rather  than 
to  those  which,  taking  their  origin  at  some  other  part  of 
the  skeleton,  have  their  insertion  in  the  flexible  vertebral 
column.  I  cannot  stop  here  to  enter  at  large  into  the  field 
which  this  conclusion  opens.  My  study  of  neuromimesis  of 
lateral  curvature  has  assisted  largely  in  reaching  this  con- 
clusion, which  is  secondary  to  other  conclusions  that  are 
stated  in  my  monograph  on  Pott's  disease,  already  alluded 
to.  I  hope  soon  to  be  able  to  especially  consider  these 
and  other  interesting  points  in  the  etiology  of  lateral  cur- 
vature, and  regret  that  the  time  allotted  me  forbids  my 
doing  it  on  this  occasion. 

The  fact  that  lateral  curvature  was  very  frequently  ac- 
companied by  hysterical  manifestation,  is  mentioned  by 
Laycock.  In  his  valuable  treatise*  he  ascribes  lateral  cur- 
vature to  "hysterical  paralysis,"  and  mentions  the  opinion 
of  Stromeyer  that  the  serratus  magnus  is  involved  in  the 
production  of  the  curvature,  a  view  which  has  since  been 
entertained  by  other  writers.  But  there  is  this  difference 
between  the  lateral  curvature  of  hysterical  origin  and  true 
scoliosis.  The  former  partakes  of  the  character  of  func- 
tional weakness,  especially  of  those  muscles  which  act  upon 
the  spinal  column  extrinsically,  while  the  latter  is  due  to  a 
progressive  muscular  contraction,  dependent  upon  causes 
yet  to  be  pathologically  ascertained,  but  which  appear  to 
primarily  affect  those  muscles  which  act  intrinsically.  The 
hysterical  form  does  not  become  true  scoliosis,  in  my  own 
experience,  unless  the  specific,  pathological  cause  be  added, 
and  we  may,  perhaps,  infer  that  this  specific  cause  is  more 
apt  to  be  developed  in  the  hysterical  diathesis,  just  as  we 
may  say  that  chronic  joint  disease  is  more  apt  to  occur 
in  the  strumous  diathesis.  Whatever  the  pathological  con- 
dition may  be,  that  induces  the  peculiar  condition  known  as 

*  An  Essay  on  Hysteria.     By  Thomas  Laycock,  Philadelphia,  1840. 


48  NEWTON  M.   SHAFFER. 

rotary  lateral  curvature,  we  at  least  know  that  the  muscular 
contraction  is  both  a  painless  and  a  progressive  one,  and 
that  it  resembles  in  character  that  found  in  true  torticollis, 
in  congenital  club-foot,  and,  in  many  instances,  in  infan- 
tile paralysis.  The  conditions  found  in  true  torticollis, 
especially  resemble  those  which  are  apparent  in  true  lateral 
curvature,  and  that  this  condition  is  one  of  contracture 
rather  than  simple  contraction,  is  confirmed  by  Paget,  who 
says,  in  speaking  of  neuromimesis  of  lateral  curvature : 
"  If  these  signs  of  distinction  are  not  enough,  etlier  or 
chloroform  will  help.  You  can  straighten  the  mimic  curv- 
ature when  the  muscles  cannot  act ;  you  cannot  so 
straighten  a  real  curvature."* 

Recognizing  then  the  character  and  persistency  of  this 
contracture,  it  is  always  a  matter  of  diiificulty — if  it  is  not 
an  impossibility,  in  the  absence  of  symptoms  in  the  earliest 
stage — to  determine  just  when  the  efficient  cause  of  the  pro- 
gressive scoliosis  commences  to  operate.  When  the  spine 
is  markedly  curved,  and  rotation  is  apparent,  the  diagnosis 
is  not  difficult,  and  while  the  tendency  of  true  scoliosis  is  to 
become  very  slowly  worse,  and  to  result  in  irremediable 
deformity,  the  hysterical  curvature,  if  properly  treated, 
sooner  or  later  recovers,  just  as  do  the  emotional  contrac- 
tions of  the  hip  or  knee. 

The  early  stage  of  hysterical  lateral  curvature,  and  the 
first  (apparent)  stage  of  true  scoliosis,  however,  present 
many  features  in  common,  and  as  before  mentioned,  the 
emotional  element  is  almost  uniformly  present  in  each. 
This  adds  to  the  difficulty  of  diagnosis — and  has  led  to 
many  errors.  For  instance,  a  young  girl  applies  for  advice. 
The  early  history  presents  no  remarkable  features.  She  has 
always  been  well — but  not  rugged — has  grown  rapidly,  and 
has  become,  of  late,  somewhat  nervous  and  easily  excited. 

*  Op.  cit.,  page  229. 


HYSTERICAL  JOINT  AFFECTIONS.  49 

Mentally,  the  patient  is  quite  active, — is  fond  of  reading — 
and,  may  be,  is  proud  of  her  position  in  class.  It  may  be 
also,  that  she  is  fond  of  out  door  sports,  but  on  the  one 
hand  everything  which  the  patient  does  is  accomplished 
with  a  tireless  sort  of  energy,  or,  on  the  other  hand,  she  may 
go  to  the  other  extreme,  and  be  very  listless  and  languid. 
Her  parents  will  tell  you  that  lately  the  spine  has  become 
crooked.  That  one  of  the  shoulder  blades  is  quite  promi- 
nent. The  patient  does  not  sit  erect,  and  when  she  stands 
one  leg  is  flexed,  and  "the  hip  "  on  the  side  opposite  the 
flexed  leg,  is  prominent.  They  fear  that  their  child  will 
become  permanently  deformed.  An  examination  shows  a 
curved  spine,  a  prominent  shoulder  blade,  a  tilted  pelvis 
with  asymmetry  of  the  trunk,  especially  between  the  free 
border  of  the  ribs  and  the  iliac  crest  on  each  side.  There 
are  tender  spots  over  the  vertebrae,  hyperaesthetic  areas 
that  change  from  time  to  time,  complaints  of  back-ache, 
sometimes  head-ache.  There  may  be  also  irregular  or  pain- 
ful menstrual  periods,  etc.  With  a  history  like  this  before 
us,  the  question  arises :  Have  we  here  a  condition  that  de- 
mands mechanical  support,  or  shall  we  simply  remove  all 
exciting  causes  and  place  the  patient  on  her  own  resources? 
If  it  be  a  condition  of  true  scoliosis,  proper  treatment  cannot 
be  too  soon  commenced,  or  too  rigidly  enforced.  If  it  be  a 
simple  "  hysterical  spine "  the  course  to  be  pursued  is 
wholly  different. 

It  is  not  unusual  to  find  a  history  closely  resembling  the 
above  developed  in  a  true  and  unmistakeable  scoliosis. 
Generally,  however,  in  this  condition  the  symptoms  are 
objective,  rather  than  subjective.  The  spine  is  curved,  the 
shoulder  projects,  but  the  patient  has  no  knowledge  of 
these  signs  herself.  Her  first  intimation  that  her  figure 
was  not  perfect,  was  derived  from  some  closely  observing 
friend,  or  the  dressmaker.     There   may  be   no   pain   at   all. 


50  NEWTON  M.    SHAFFER. 

The  disturbed  muscular  action,  whatever  be  its  cause,  does 
its  work  painlessly,  but  none  the  less  surely. 

Rotation  of  the  vertebrae  is  described  by  Barwell,  Adams, 
and  others  as  occurring  very  early  in  the  history  of  true 
scoliosis.  My  own  experience  confirms  this,  and  its  value 
as  a  diagnostic  sign  in  the  first  stage  is  very  great.  In  my 
own  experience  also  the  first  (apparent)  stage  of  true  sco- 
liosis is  always  accompanied  by  a  modification  of  the  lateral 
flexibility  of  the  vertebral  column,  in  the  dorsal  region, 
while  in  the  neuromimetic  state,  this  modification  does  not 
exist.  The  loss  of  symmetry  between  the  scapulae  in  true 
scoliosis  depends,  mostly,  upon  the  acquired  position  of 
the  ribs,  and  in  the  mimic  state,  there  is  a  simple 
debility  of  the  scapular  muscles,  without  any  change 
in  the  ribs  whatever.*  In  the  simulated  state  there  is 
generally  an  excurvated  spine  with  a  lateral  deviation, 
while  in  true  scoliosis  the  curvature  is  lateral  wholly,  with 
compensatory  or  double  curves.  And  these  facts  enable 
us  to  mention  the  symptoms,  which  when  found,  render 
the  diagnosis  of  lateral  curvature  certain,  viz.,  rotation  of 
the  vertebrae,  and  marked  resistance  to  lateral  flexion  on 
that  side  toward  which  the  convexity  of  the  dorsal  curve 
looks. 

Another  point  is  this:  Like  the  symptomatic  lateral 
curvature  found  in  chronic  coxitis,  or  which  arises  from  any 
cause  which  affects  the  transverse  pelvic  plane,  the  neuro- 
mimetic spine  becomes  straightened,  and  the  scapulae  as- 
sume their  normal  relations  when  the  patient  is  placed  in 
the  prone  position.  Absolute  rest  of  the  long,  extrinsic 
muscles  of  the  vertebral  column  is  all  that  is  necessary  to 
restore  the  parts  to  their  normal  position.  After  very  evi- 
dent rotation  and  marked  lateral  resistance  are  met  with, 
recumbency  fails  to  wholly  annul  the  curvature,  though  in 

*  Paget  remarks  "the  vertebrae  are  little  or  not  at  all  rotated,  as  they  are  in 
well-marked  cases." — Op.  cit.,  p.  229. 


H  YS  TERICA  L  JOIN  T  A  FFE  C  TIONS.  5  I 

removing  the  contributive  cause  of  gravity,  which  acts  ver- 
tically when  the  patient  sits  or  stands,  the  position  of  the 
shoulder  blades  and  the  curvature  itself  becomes  consider- 
ably modified. 

But  if,  after  examining  a  patient  carefully,  making  accu- 
rate notes  of  your  observations,  you  should  still  fail  to 
reach  a  satisfactory  conclusion,  ii  may  be  deemed  advisable 
to  ask  another  examination  at  an  early  day.  If  during  the 
interim  any  marked  change  in  the  symptoms  occur,  the 
evidence  is  strongly  in  favor  of  neuromimesis.  There  is 
"  no  alternation  of  increase  or  remission"  in  the  muscular 
conditions,  or  the  deformity,  in  true  scoliosis.  The  shoul- 
der blade  does  not  change  its  position  from  day  to  day. 
The  curvature  and  the  rotation  progress  slowly,  obeying 
the  mandates  of  the  incessant  muscular  contraction,  but  so 
slowly,  that  weeks  may  elapse  without  presenting  any  ex- 
ternal change  that  the  eye  could  appreciate.  In  the  mimic 
state  various  and  sometimes  very  marked  changes  occur  in 
a  few  days.  And  if  we  find  that  these  variations  are  not 
associated  with  the  permanent  features  of  the  true  scoliosis, 
which  have  already  been  mentioned,  there  is  no  doubt  as 
to  the  existence  of  a  neuromimetic  state. 

The  treatment  of  hysterical  lateral  curvature  will  depend 
very  greatly  upon  the  extent  of  the  debility  of  the  extrin- 
sic spinal  muscles,  and  the  consequent  malposition  of  the 
spine  and  scapulae.  In  many  cases  we  can  overcome  the 
purely  functional  inertia  of  the  spinal  muscles,  by  suitable 
exercises,  etc.  But  if  the  patient  be  a  rapidly  growing  girl, 
either  just  approaching,  or  just  past  her  menophania,  more 
radical  measures  may  be  demanded.  If  the  muscular  lassi- 
tude be  great,  and  the  malposition  a  constant  attendant  of 
the  standing  or  sitting  position,  it  has  been  my  habit  to 
apply  a  very  light  and  closely-fitting  elastic^  steel  support. 
By  its  use  we  can  succeed  in  antagonizing  the  dorso-lumbar 


52  NEWTON  M.   SHAFFER. 

excurvation,  and  thus  secure  the  normal  antero-posterior 
curves  of  the  vertebral  column.  If  the  normal  antero- 
posterior curves  are  successfully  maintained,  the  lateral 
deviation  as  well  as  the  drooping  scapula  seem  to  care  for 
themselves. 

This  support  consists  of,  ist.  Two  light  steel  uprights, 
bent  in  the  line  of  the  normal  curves  of  the  spine,  with  the 
anterior  dorso-lumbar  curve  slightly  exaggerated.  These 
uprights  are  then  tempered  ;  2d.  A  pelvic  band,  reaching 
from  trochanter  to  trochanter,  to  the  centre  of  which  these 
uprights  are  rivited,  as  in  the  conventional  spinal  brace 
for  Pott's  disease ;  3d.  An  anterior  bandage  or  '.'  apron," 
which  secures  these  uprights  and  the  pelvic  band  firmly 
against  the  body ;  4th.  The  customary  axillary  pads,  which 
pass  from  the  upper  termination  of  the  uprights  (about  the 
second  dorsal)  to  a  crosspiece  opposite  the  lower  angles  of 
the  scapulae.  The  resistance  afforded  by  this  simple  sup- 
port is  sufificient  to  hold  the  vertebral  column  in  the  desired 
position,  and  yet  the  apparatus  in  no  way  interferes  with 
natural  or  even  graceful  movements ;  and  the  muscles, 
though  supported,  are  not  deprived  of  exercise  and  use. 
This  support  also  is  worn  a  part  of  the  day  only,  as  a 
rule,  suitable  exercises,  massage,  faradism,  etc.,  being  used 
as  circumstances  indicate.  Usually  the  support  can  be  re- 
moved after  a  few  weeks  or  months. 

If  space  permitted,  I  might  add  cases  illustrating  neuro- 
mimesis  of  disease  of  the  ankle,  elbow,  wrist  and  shoulder 
joints.  And  I  have  seen  two  or  three  mimic  cases  that 
might  easily  be  called  sacro-iliac  disease,  so  closely  did  the 
symptoms  coincide  with  those  which  have  been  recently 
described  as  being  present  in  the  first  stage  of  this  truly 
formidable  lesion.  It  would  be  impossible,  however,  to 
cover  the  entire  field  of  the  nervous  mimicry  of  joint  dis- 
eases in  one  evening.     The  same  rules,  and  the  conclusions 


HYSTERICAL  JOINT  AFFECTIONS.  53 

deduced  from  our  study  of  the  mimicry  of  knee,  hip  and 
spine  diseases,  are  equally  applicable  to  the  differential 
diagnosis  of  the  true  and  false  lesions  of  other  articulations. 

o 

Hysterical  club-foot  is  not  of  very  frequent  occurrence, 
though  a  distorted  ankle  joint  may  frequently  accompany 
other  contractions  of  an  hysterical  character  at  the  knee  and 
hip.  Laycock  states,  "  that  local  hysterical  paralysis  will 
give  rise  to  a  distortion  of  the  foot,""^  and  Shawf  describes 
a  case  in  which  the  "  ankle  was  at  this  time  turned  round, 
so  that  she  walked  on  the  outside  of  her  foot."  Dr.  W.  J. 
Little,  in  his  classical  treatise  on  Club  Foot,:j:  thus  describes 
the  position  of  the  foot  in  a  case  of  talipes  varus  acquisitus 
(hystericus)  in  a  girl  of  19:  "  its  outer  margin  alone  touch- 
ing the  ground,  the  sole  presenting  vertically  backward,  the 
tibialis  anticus,  tibialis  posticus  and  gastrocnemii  tendons 
being  tense  from  contraction  of  their  respective  muscles, 
and  toes  firmly  incurvated  ;  she  was  unable  to  rest  on  the 
limb,  the  attempt  being  followed  by  an  outward  yielding  of 
the  tarsus,  which  brought  the  superior  surface  of  the  os 
cuboides  to  the  ground.  Locomotion  could  only  be 
effected  with  crutches."  Another  case  is  also  mentioned  by 
the  same  writer :  "  Wherein  contraction  of  the  right  ante- 
rior tibial  muscle  has  been  erroneously  considered  the  sole 
cause  of  the  distortion,  and  for  the  cure  of  which  its  tendon 
had  been  divided.  I  found  that  contraction  of  the  pos- 
terior tibial  muscle  was  the  cause  of  the  continuance  of 
deformity." 

Skey  relates  the  following  very  interesting  case  :§ 

"  In  the  year  1864  a  young  lady  of  16  years  of  age  was  placed 
under  my  care  under  the  following  circumstances  : 

*  Op.  cit.,  page  130. 

f  Further  observations  on  Distortion  of  the  Spine.  By  John  Shaw,  page  184, 
London,  1825. 

X  Club  Foot  and  Analagous  Distortions.  By  W.  J.  Little,  M.D.,  F.R.C.S., 
page  229.     London,  1839. 

§  Op  cit.,  page  104. 


54  NEWTON  M.  SHAFFER. 

For  eight  months  prior  to  her  visit  to  me,  she  had  been  suffer- 
ing from  inversion  of  her  left  foot,  which  was  so  twisted  as  to 
bring  the  point  of  the  foot  to  the  opposite  ankle.  *  *  *  Her 
family  consulted  a  surgeon  of  much  experience  in  the  treatment  of 
distortions  and  of  orthopaedic  notoriety.  The  case  was  considered 
as  an  example  of  an  ordinary  distortion,  and  the  foot  was  placed 
in  a  very  elaborately  made  foot  splint,  by  the  force  of  which  it 
was  made  to  approach  a  parallel  relation  with  the  other  foot  ;  but 
it  was  an  approach  only,  for  no  mechanism  could  retain  it  in  a 
perfect  position,  the  toes  yet  in  some  degree  pointing  inward. 
Months  elapsed,  and  the  disease  continued  unchanged.  A  sec- 
ond orthopaedic  authority  was  then  consulted,  in  conjunction  with 
the  first,  and  as  no  new  light  was  thrown  on  the  disease  by  the 
combined  opinions  of  the  two,  the  same  principle  of  treatment 
was  recommended  to  be  continued,  and  the  mechanism  was  some- 
what more  elaborated.  *  *  *  When  the  apparatus,  which  she 
had  worn  so  long  was  removed  on  the  occasion  of  her  visit  to  me, 
her  foot  immediately  resumed  its  twisted  form.  *  *  *  The  dis- 
ease had  appeared  almost  suddenly,  in  a  person  hitherto  healthy. 
It  could  not  be  due  to  congenital  deformity,  and  the  limb  gave  no 
indication  of  disease  or  disorganization.  There  was  neither  pain, 
heat  or  swelling.  In  this  case,  also,  there  was  no  catamenial  de- 
rangement. 

I  removed  the  apparatus  from  the  foot,  bandaged  the  limb  with 
a  calico  roller,  ordered  a  full,  nutritious  diet,  with  bark  and  iron, 
and  having  explained  the  nature  of  the  disease  to  a  friend,  sent 
the  young  lady  home  into  the  country,  recommending  her  to  rely 
on  the  kindly  offices  of  nature — the  greatest  of  all  doctors,  ortho- 
paedists not  excepted.  At  the  end  of  a  month  some  progress  had 
been  made,  but  not  a  great  deal.  She  still  walked  with  some  dif- 
ficulty, but  it  was  obvious  that  she  was  improving  in  health  and 
vigor  of  system.  At  the  expiration  of  six  weeks  she  accompanied 
her  family  to  a  ball,  her  foot,  as  she  entered  the  ball-room  being 
not  yet  restored  to  its  normal  position.  She  was  invited  to  dance 
and  under  the  novel  excitement  she  stood  up,  and,  to  the  as- 
tonishment of  her  family,  she  danced  the  whole  evening,  having 
almost  suddenly  recovered  the  healthy  muscular  actions  of  the 
limb  !  She  came  to  see  me  two  days  afterward.  She  walked 
perfectly  well  into  my  room,  and  paced  the  floor  backward 
and  forward  with  delight.  The  actions  of  the  limb  were  thor- 
oughly restored,  and  all  traces  of  the  previous  malady  had  disap- 
peared." 


//  VS  T ERICA  L  JOIN  T  A  FFE  C  TIONS.  5  5 

Charles  Bell  also  relates  a  case  *  in  his  work  on  "  The 
Nervous  System  of  the  Human  Body."  Charcot  mentions 
"a  most  interesting  case,"  communicated  to  the  Medical  So- 
ciety of  Ghent,  by  Dr.  R.  Boddaert.f  Adams  dismisses  the 
matter  with  the  following  remark :  "  A  very  severe  and 
obstinate  form  (of  talipes)  is  observable  in  young  girls 
which  is  evidently  connected  with  hysteria,  and  I  need 
hardly  say  that  in  these  cases  the  treatment  must  be  direct- 
ed against  the  general,  rather  than  the  local  affection."  :|: 
Brodhurst  relates  very  briefly  a  case  in  which  certain  mus- 
cles were  contracted,  bringing  "  the  outer  edge  of  the  ante- 
rior portion  of  the  foot  to  the  ground,  the  inner  surface  be- 
ing raised,  and  the  heel  fully  an  inch  from  the  ground, "§ — 
but  this  condition  was  not  permanent,  and  occurred  during 
the  catamenial  periods  only.  Not  to  refer  individually  to 
all  the  authors  who  have  written  upon  orthopaedic  surgery 
or  club  foot,  I  will  briefly  state  that  the  seeker  after  infor- 
mation upon  hysterical  deformities  will  be  greatly  disap- 
pointed, especially  when  consulting  the  most  popular  Amer- 
ican authorities.  Many  writers  on  diseases  of  the  nervous 
system  also  practically  ignore  this  subject — or  merely  men- 
tion the  existence  of  such  conditions,  and  several  works 
which  I  have  consulted  do  not  even  refer  to  hysterical  club 
foot.  As  the  nervous  mimicry  of  club  foot  is  not  always 
easy  of  diagnosis,  and  as  the  treatment  required  is  different 
from  that  which  is  applicable  to  the  ordinary  forms  of  tali- 
pes, the  errors  likely  to  ensue  make  a  brief  study  of  these 
cases  profitable. 

I  have  seen  four  cases  of  hysterical  club  foot.  In  one  of 
these  cases  there  was  contraction  also  at  the  knee  and  hip. 
In  one  (Case    12),  the  distortion  came  on  after  emotional 

*  Referred  to  by  Charcot. 

\  Annales  de  la  Societe  de  Medecine  de  Gand,  1859,  p.  93. 
:j;Club  Foot.      Its   Causes,  Pathology  and  Treatment,  by  William  Adams,  F. 
R.  C.  S.     2d  ed.      London,  1873. 

§  Brodliurst  on  "'  Club  Foot."     London,  1856. 


56  NEWTON  M.   SHAFFER. 

excitement,  and  other  symptoms  which  will  be  described. 
The  third  occurred  in  niy  private  practice  and  was  placed, 
at  my  request,  in  St.  Lukes  Hospital,  where  it  was  attend- 
ed conjointly  by  my  friend  and  colleague.  Dr.  G.  G.  Whee- 
lock  and  myself.  This  patient,  a  precocious  and  emotional 
girl  of  II,  presented  many  peculiar  symptoms,  and  was  dis- 
charged unimproved.  She  afterward  recovered  at  home, 
I  am  informed,  under  severe  measures  instituted  by  her 
father.  The  following  case  may,  however,  be  called  a  typical 
one,  and  as  ample  opportunity  was  afforded  for  several  ex- 
aminations, I  append  the  history  in  full. 

Case  ii. — In  June,  1878,  I  was  called  to  see  Miss  H ,  aged 

19,  living  on  Long  Island,  at  the  suggestion  of  Dr.  A.  G.  Thomp- 
son, of  Islip.  The  patient  was  incapacitated  by  a  club-foot— which 
was  almost  daily  becoming  more  troublesome. 

The  history  developed  was  as  follows  :  In  a  hereditary  sense 
there  was  nothing  of  special  importance,  except  that  a  paternal  aunt 
had  "  died  from  some  lingering  nervous  disease."  The  parents  of 
the  patient  were  living  and  were  in  good  health. 

The  patient  had  rheumatism  when  she  was  three  years  old,  and  for 
the  three  or  four  years  succeeding  this  attack  suffered  from 
recurrence  of  the  same  disease.  Up  to  the  age  of  fourteen,  when 
menstruation  appeared,  she  had  been  otherwise  healthy.  At  the 
age  of  fourteen  a  severe  attack  of  inflammatory  rheumatism  oc- 
curred. In  1877,  my  friend,  Dr.  Charles  W.  Packard  examined 
the  patient  and  found  her  to  be  suffering  from  organic  heart  dis- 
ease, a  condition  (aortic  regurgitant),  which  was  evident  at  the 
time  I  examined  the  case.  The  patient  had  never  been  especially 
emotional,  and,  to  outward  appearance,  was  in  good  health. 

On  the  evening  of  February  22,  1878,  she  was  seized  with  diffi- 
cult breathing,  pain  in  the  region  of  the  heart,  and  various,  irregu- 
lar, convulsive  movements.  There  was,  in  the  course  of  the  next 
few  days  a  repetition  of  these  attacks,  and  they  finally  culminated 
in  typical  hysterical  convulsions,  with  opisthotonos,  etc.  Various 
remedies  were  used,  and  after  many  fruitless  efforts  it  was  found 
that  they  could  be  best  controlled  by  full  doses  of  morphine.  The 
effect  of  these  attacks  was  to  induce  great  debility.  The  patient 
could  walk  very  well,  but  there  was  no  deformity  of  the  foot. 
Soon  after,  with  no  other  manifestations  of  importance,  the  urine 


HYSTERICAL  JOINT  AFFECTIONS.  5/ 

became  suppressed,  and  for  72  hours  there  was,  apparently,  no 
urine  secreted  at  all.  When  the  bladder  was  emptied,  there  was 
found  to  be  only  a  comparatively  small  quantity.  Morphine  ac- 
complished more  than  any  other  remedy  in  temporarily  restoring 
the  secretion  of  urine,  as  in  the  case  of  hysterical  anuria  recently 
reported  by  Drs.  McBride  and  Mann.*  After  this,  on  several 
occasions,  hysterical  symptoms  manifested  themselves,  until,  on 
April  21,  1878,  the  patient  began  to  walk  upon  the  outside  of  the 
right  foot.  There  was  no  pain  in  the  limb  anywhere,  except  that 
occasioned  by  undue  pressure  over  the  cuboid  bone. 

After  the  appearance  of  the  deformity  the  patient  became  greatly 
disinclined  to  take  exercise  of  any  kind,  partly  on  account  of  th^ 
pain  produced  by  walking,  and  partly  on  account  of  an  avowed 
indifference.  Her  principal  occupation  had  been  embroidery  or 
reading.  At  the  time  of  examintion  she  walked  with  a  very  awk- 
ward gait,  limping  very  much,  and  the  knee  seemed  to  possess 
very  little  strength.  The  position  of  the  foot  was  that  of  uncom- 
plicated varus.  I'he  abductor  pollicis  pedis,  the  plantar  muscles, 
the  tibialis  posticus  and  anticus  as  well  as  the  gastrocnemius  were 
very  rigid,  and  the  ankle-joint  seemed  actually  anchylosed.  I 
made  various  attempts  to  overcome  the  evident  muscular  contrac- 
tions, but  without  avail.  The  position  was  not  changed  by  ma- 
nipulation during  sleep.  There  was  slightly  reduced  sensation 
below  the  knee,  but  no  hyperaesthetic  areas  existed.  There  was 
no  atrophy. 

A  diagnosis  of  hysterical  contracture  was  made.  The  warm 
weather  was  approaching,  and  it  was  deemed  advisable  to  give  the 
patient  the  benefit  of  a  change  of  scene  and  air,  with  the  hope  that 
spontaneous  recovery  would  ensue. 

On  September  12,  1878,  the  patient  came  to  the  city  improved 
as  to  general  health.  Neither  seashore  nor  mountain  air  had, 
however,  affected  the  condition  of  the  contracture.  Before  insti- 
tuting any  decided  measures  in  the  way  of  treatment,  I  thought  it 
best  to  ask  for  a  consultation,  in  view  of  the  cardiac  complication. 
Dr.  E.  C.  Seguin  examined  the  patient  with  me,  and  a  course  of 
treatment  was  decided  upon,  and  the  parents  of  the  patient  were 
informed  as  to  the  condition  of  the  heart,  and  the  possible  effect  of 
treatment,  both  upon  the  heart  lesion  and  the  deformity  itself. 
After  due  deliberation,  the  father  decided  to  make  no  effort  in  the 
way  of  treatment.     The  patient  returned  to  her  home,  and  has 

*  A  case  of  Hysterical  Anuria  Cured  by  Restoring  a  Lacerated  Cervix  Uteri. 
Archives  of  Medicine,  June,  1879. 


58 


NE  IV TON  M.   SHAFFER. 


since  remained  tolerably  well,  though  I  am  informed  that,  of  late, 
the  opposite  foot  has  shown  a  decided  tendency  to  assume  the 
same  position  as  the  one  which  was  first  deformed. 


The  position  of  the  foot  is  shown  in  the  accompanying 
engraving.  As  a  matter  of  comparison,  both  feet  are  rep- 
resented. It  will  be  noted  that,  in  addition  to  the  varus  posi- 
tion, there  is  a  peculiar  and  extreme  flexion  of  the  toes.  In 
every  case  of  hysterical  talipes  I  have  seen,  this  same  peculiar 
flexion  occurred,  and  a  reference  to  Charcot's  cases  of  hysteri- 
cal contracture  of  the  lower  extremities,  will  demonstrate  this 
same  characteristic  sign  of  hysterical  affections  of  the  foot. 
In  true  talipes  this  condition  does  not  often  exist,  and  its 
presence  may  be  looked  upon  as  an  indication  of  the  hys- 
terical state. 

The  following  case  presents  many  interesting  and  in- 
structive features,  and  illustrates  the  many  phases  "  hy- 
steria "  may  assume  in  boys  of  tender  years,  including  even 
a  neuromimesis  of  club-foot. 


Case  12. — Willie  M ,  aged  10  years,  residence  Bridgeport, 

Connecticut.  I  saw  the  case  first  in  consultation  with  Dr.  D.  H. 
Nash,  September  29,1877.  Hereditary  history  good  :  no  circum- 
stance to  note  in  early  life. 

While  attending  a  military  review  in  August,  1877,  the  patient 
fell,    striking   his    back   against   the  fluke    of    an    anchor.       The 


HYSTERICAL  JOINT  AFFECTIONS.  59 

third  lumbar  was  the  point  of  injury  and  the  evidences  of  the 
contusion  caused  thereby  were  evident  for  several  days.  While 
they  were  still  present,  about  one  week  after  the  fall,  he  complained 
of  weakness  in  his  limbs,  and,  one  night  when  ready  for  bed,  he 
said  he  could  not  walk  ;  he  crawled  up  stairs  on  his  hands  and 
knees.  The  following  morning  he  was  much  worse,  was  unable 
to  stand  alone  and  complained  of  great  pain.  The  family  physi- 
cian was  called  in,  who,  after  hearing  the  symptoms,  asked  "  Have 
you  hurt  your  back  in  any  way  ?  "  Not  an  unnatural  question 
under  the  circumstances,  and  the  patient  who  had  apparently  for- 
gotten the  fall,  recalled  it  and  related  the  circumstances  thereof  to 
the  doctor.  The  spine  was  examined  and  a  tender  spot  discovered 
at  the  point  of  injury.  Counter  irritation  (croton  oil),  and  rest 
were  prescribed.  The  patient  became  worse  :  extreme  pain  in  the 
back  prevented  his  being  moved  in  bed  and  soon  he  could  not 
move  his  limbs.  Then  there  was  an  apparent  loss  of  sensa- 
tion, for  he  professed  utter  indifference  when  pinched,  or  even 
pricked  with  a  needle,  especially  in  the  right  lower  extremity  ; 
both  limbs,  especially  the  right,  became  cold.  Such  was  the  his- 
tory given  to  me  by  Dr.  Nash  and  the  parents  of  the  boy.  I  copy 
the  remainder  from  my  case-book. 

Examination. — September  29, 1877.  Patient  in  bed  ;  countenance 
pale  and  apprehensive  ;  complains  very  much  at  any  attempt  to 
change  position  ;  severe  pain  located  in  back  in  region  of  third 
lumbar  vertebra  ;  pulse  95  ;  auxiliary  temperature  98.4°.  Is  unable 
to  move  lower  extremities,  which  show  a  reduced  temperature  as 
tested  by  Seguin's  surface  thermometer.  Normal  joint  motion  in 
lower  extremities,  except  at  the  right  hip  joint  where  a  marked 
psoas  resistance  was  met,  such  as  is  frequently  found  in  the  first 
stage  of  chronic  spondylitis,  in  the  region  suspected  ;  but  this  re- 
sistance yielded  to  a  gentle  and  continuous  force  ;  rotation  of 
thighs  normah  At  the  expense  of  a  good  deal  of  pain,  the  verte- 
bral column  was  proven  to  be  normally  flexible  in  all  directions 
at  the  point  of  injury.  The  faradic  reaction  of  the  muscles  of  the 
left  leg  and  thigh  was  normal,  taking  the  biceps  cubiti  as  the 
standard.  On  the  right  side,  however,  there  was  a  very  evi- 
dent reduction,  in  the  reaction  of  the  quadriceps  extensor 
cruris  and  the  peronei.  There  was  also  a  very  consider- 
erable  anaesthesia,  especially  of  the  right  thigh  and  leg.  A  further 
examination  of  the  vertebral  column  by  palpation,  demonstrated 
pain  on  slight  pressure  at  the  seventh  cervical  vertebra  and  at  the 
point  of  injury,  which  still  showed  the  peculiar  eruption  of  the 
croton  oil. 


6o  NE  WTON  M.   SHAFFER. 

In  the  vicinity  of  the  third  himbar  there  was  marked  hyper- 
sesthesia  ;  bladder  and  rectum  normal,  though  the  former  had  per- 
formed its  function  with  some  hesitancy.  No  cerebral  symptoms  ; 
reflex  movements  as  induced  by  titillation  of  the  soles  of  the  feet 
very  considerably  reduced  on  both  sides.  No  apparent  atrophy  of 
either  limb  ;  limbs  equal  in  length  and  circumference. 

There  was  no  history  of  fever,  though  early  thermometrical  ob- 
servations had  not  been  taken,  and  no  other  acute  symptoms  were 
noted  than  those  above  mentioned.  The  apparently  excruciating 
pain  was  excited  by  any  movement,  especially  by  a  sudden  jar ; 
it  was  with  great  difficulty  that  the  patient  was  raised  sufficiently 
to  permit  the  use  of  a  bed  pan,  and  the  bed  linen  though  soiled, 
had  not  been  changed  for  many  days. 

In  reviewing  the  case  in  consultation,  I  declined  to 
make  a  positive  diagnosis  with  only  one  examination. 
Two  conditions  presented  :  a  lesion  of  the  spinal  column 
(which  had  been  strongly  suspected)  was  eliminated  by 
the  normal  flexibility  of  the  spine  at  the  suspected  point 
and  the  absence  of  other  symptoms  which  would  positively 
indicate  chronic  spondylitis. 

1st.  An  obscure  lesion  of  the  spinal  cord,  the  early  symp- 
toms of  which  had  been  overlooked,  leaving  a  slight  sensor 
and  motor  paresis  of  the  right  leg.  The  fact  that  the  ex- 
ternal evidences  of  injury  were  located  below  the  termina- 
tion of  the  spinal  cord  was  commented  upon  at  the  consul- 
tation. 

2d.  A  neuromimesis.  I  inclined  decidedly  to  the  latter, 
and  so  expressed  myself.  I  advised  the  continuance  of  the 
recumbent  posture,  tonics,  and  recommended  a  careful 
avoidance  of  any  allusion  to  the  patient's  condition  in  his 
presence,  and  suggested  that  the  counter  irritants  be  dis- 
continued. The  patient  was  to  be  lifted  daily  upon  a 
blanket,  and  the  bed  linen  changed.  A  second  consultation 
was  arranged  for  a  few  days  later. 

October  3c/. — Upon  entering  the  room,  I  proposed  to  move  the 
l)'^d  so  as  to  obtain  a  better  light.     To  this  the  patient  made  ur- 


HYSTERICAL  JOINT  AFFECTIONS.  6 1 

gent  objection,  and  burst  into  tears.  A  promise  that  the  bed 
should  not  be  moved  restored  his  equilibrium.  Axillary  tempera- 
ture normal  ;  pulse  85  ;  no  change  in  the  faradic  reaction  of  the 
muscles  of  either  limb  ;  anaesthesia  still  present  ;  apparent  psoas 
contraction  which  yielded  to  manipulation  as  before.  The  pain 
in  the  back  was  worse  rather  than  better  ;  appetite  fair  ;  blad- 
der and  rectum  normal  ;  but  f/ie  muscles  of  each  lower  ex- 
tremity were  very  rigid,  and  it  rec[uired  both  time  and  tact  to 
demonstrate  that  this  rigidity  could  be  overcome,  but  the  pa- 
tient's mind  being  diverted,  this  condition  ceased  suddenly,  and 
free  passive  motion  was  permitted,  but  apparently  at  the  ex- 
pense of  greatly  aggravating  the  pain  in  the  back.  Adherent 
prepuce  and  masturbation  had  been  eliminated  from  the  case. 

The  irregular  character  of  many  of  the  symptoms, 
the  exaggerated  quality  of  those  that  did  present  with 
anything  like  constancy,  the  absence  of  definite  indica- 
tions of  a  cord  lesion,  and  the  certainty  that  there  was  no 
osseous  lesion,  determined  the  case,  in  my  mind,  to  be 
hysterical.  Feeling  that  I  had  the  confidence  both  of  the 
parents  of  the  child  and  of  the  child  himself,  I  deliberately 
lifted  the  boy  from  his  bed,  bore  him  across  the  room,  and 
placed  him  in  an  easy  chair  by  the  window.  Supporting 
the  rigid  limbs  first  with  my  hands,  and  then  upon  my 
knees,  I  called  his  attention  to  some  passing  object.  The 
rigid  muscles  again  relaxed. 

After  some  assumed  hesitation  on  my  part,  I  permitted 
the  patient  to  sit  up  for  half  an  hour,  watching  him  closely. 
The  pain  in  the  back  disappeared,  and  when  I  left  to  return 
to  town,  he  was  sitting  up  in  his  bed,  eating  his  supper 
with  good  relish.  Instructions  were  given  to  make  him  leave 
his  bed  the  following  morning.  He  was  to  go  out  of  doors 
every  day,  where  he  was  to  be  allowed  to  do  as  he  pleased. 
The  following,  quoted  from  a  letter  which  I  received  from 
his  father  a  short  time  after,  will  show  the  success  of  this 
plan  of  treatment :  "  Your  patient  sat  up  on  Sunday  (the  day 
following  your  second  examination),  walked  all  about  the 


62  NEWrON  M.   SHAFFER. 

house  on  Monday,  was  out  of  doors  walking  and  riding  on 
Tuesday,  and  every  day  since  he  has  kept  it  up.  He  walks 
a  little  stiffly  or  weakly,  but  without  a  cane  or  any  as- 
sistance." The  improvement  continued,  and  the  boy 
soon  walked  naturally. 

About  three  weeks  later  the  father  of  the  patient  found  it  neces- 
sary to  deny  him  some  favor  which  he  had  asked.  The  pa- 
tient sobbed  convulsively,  threw  himself  upon  the  floor  and 
cried  bitterly  for  upward  of  an  hour.  The  father  did  not  yield, 
and  the  child  finally  submitted  and  went  to  bed.  The  next  morn- 
ing a  new  symptom  developed.  The  left  foot  assumed  the  posi- 
tion of  talipes  equino-varus.  I  was  again  summoned  to  examine 
the  boy,  whom  I  found  playing  ball,  but  walking  very  badly. 
Had  it  been  the  right  foot  that  was  affected,  I  would  not  have 
been  surprised,  for  the  peronei  of  the  right  leg  had  shown  a  di- 
minished faradic  reaction  at  both  of  my  previous  examinations. 
An  exainination,  however,  cleared  the  matter  up  :  the  peronei 
of  the  left  leg  showed  normal  contractility,  the  right  alone  giving 
diminished  reaction.  No  other  new  symptom  presented.  Pain 
in  the  back  had  wholly  disappeared,  though  the  anaesthesia  of  the 
right  leg  still  remained  to  a  slight  extent.  The  psoas  contrac- 
tion was  gone.  No  attention  was  to  be  given  to  the  "  turning  of 
the  foot,"  and  stimulated  by  a  promise  that  he  should  have 
some  money  with  which  to  buy  Christmas  presents  if  he  over- 
came this  trouble,  it  gradually  disappeared,  and  has  never  re- 
turned. 

The  diminished  faradic  reaction,  the  anaesthesia,  the  uni- 
lateral psoas  contraction  and  the  greatly  modified  reflex 
action  were  the  symptoms  in  this  case  that  threw  doubt 
upon  the  diagnosis.  They  are  all  compatible  with  the  early 
hysterical  state  except  the  one  first  mentioned,  and  this 
condition  remained  after  the  boy's  recovery. 

Great  care  is  necessary  in  determining  the  quality  of  the 
faradic  reaction  in  suspected  muscles,  where  the  modifica- 
tion of  the  contractility  is  slight.  My  usual  procedure  was 
suggested  by  Dr.  Seguin,  and  serves  a  good  purpose.  I  use 
the  five-post  Kidder  (tip)   battery,  and  first  find  the  normal 


■  HYSTERICAL  JOINT  AFFECTIONS.  63 

reaction  of  the  biceps  cubiti.  With  this  as  a  standard,  I 
test  the  muscles  of  the  sound  limb,  and  the  superficial  mus- 
cles will  generally  respond  to  the  same  current.  The  cylin- 
der of  the  battery  is  marked  in  fractions  of  an  inch.  I  then 
test  the  suspected  muscles  with  the  same  current,  and  in- 
crease its  strength  until  the  point  of  evident  reaction  is 
reached.  A  difference  sufficient  for  diagnostic  purposes  can 
thus  be  demonstrated. 

The  treatment  of  hysterical  contracture*  is,  as  a  rule, 
very  unsatisfactory,  and  the  issue  is  sometimes  doubtful. 
Many  cases  recover  spontaneously,  while  others  persist  for 
years. 

In  one  of  Dr.  Little's  cases  of  hysterical  club  foot,  opera- 
tive measures  were  completely  successful.  In  other  cases, 
after  various  remedial  agents  had  failed,  recovery  has  taken 
place  at  a  time  and  under  circumstances  which  involved  an 
unexpected  demand  upon  the  volition  of  the  patient,  or 
under  some  form  of  emotional  excitement.  Purely  mechan- 
ical treatment  is  apt  to  prove  very  unsatisfactory,  and  if 
used  at  all,  preference  should  be  given  to  cases  of  confirmed 
hysterical  paralysis,  where  all  other  means  have  failed,  or 
to  the  more  exaggerated  forms  of  hysterical  spinal  curva- 
tures, where  some  simple,  elastic  support  is  indicated.    And 

*  I  am  indebted  to  my  friend,  Dr.  Mary  Putnam  Jacobi,  for  tlie  following 
extract  from  Duchenne's  "  De  V Electrisation  localise'e"  2d  ed.,  p.  926.  "  Ttie 
following  is  a  i-emarkable  example  of  a  rapid  cure  of  an  hysterical  contracture 
of  the  masseters,  which  had  existed  for  two  years."  Obs.  CCXIV  (condensed). 
The  contracture  came  on  without  any  appreciable  cause  other  than  the  hysterical 
state.  Alimentation  being  difficult,  an  apparatus  had  been  made  which  main- 
tained the  jaws  slightly  apart,  and  which  was  constantly  worn.  The  contracture 
disappeared  under  chloroform,  but  it  reappeared.  It  had  disappeared  sponta- 
neously on  one  occasion,  and  had  existed  continuously  for  six  months,  when, 
after  failure  under  the  care  of  Drs.  Campbell  and  Nelaton,  it  came  under 
Duchenne's  observation.  The  contracture  disappeared  entirely  under  the  in- 
fluence of  "  electro-cutaneous  excitation" — two  applications. 

A  case  of  hysterical  contraction  of  the  thumb,  in  a  girl  of  ten,  recently  applied 
at  the  Orthopaedic  Dispensary.  It  had  existed  for  several  months.  The  patient 
wore,  under  my  direction,  a  splint  for  about  ten  days.  She  was  then  transferred 
to  Dr.  Clovis  Adam,  Electro-Therapeutist  to  the  Dispensary.  Three  applica- 
tions of  a  strong  faradic  current  to  the  antagonistic  muscles  produced  a  complete 
recovery.  And  Dr.  Adam  also  reports  a  case,  in  a  woman  of  25,  of  hysterical 
contraction  of  the  hand  and  thumb,  also  completely  relieved  by  similar  meas- 
ures. 


64  NE  WTON  M.   SHAFFER. 

even  in  these  instances,  the  use  of  apparatus  should  be 
made  secondary  to  other  measures.  The  appHcation  of  me- 
chanical force  to  overcome  the  deformities  induced  by  hys- 
terical contracture  is  positively  contra-indicated.  In  the 
case  of  Miss  H.,  Dr.  Seguin  proposed  the  use  of  atropia, 
hypodermically,  in  heroic  doses,  and  the  application  of 
faradism,  locally.  The  use  of  apparatus  was  not  even  dis- 
cussed. 

At  his  examination  of  this  patient  (Miss  H.,)  Dr.  Seguin 
tested  the  electrical  conditions  of  the  muscles  of  the  affected 
limb.  The  following  is  extracted  from  his  note-book  : — "  Ex- 
ternal popliteal  nerves  react  equally  (both  sides)  to  faradic 
current  of  weak  power;  muscles  of  anterior  tibial  and  of 
peroneal  regions  react  on  both  sides  to  same  current,  but 
right  peronei  contract  less  because  of  their  stretched  state. 
Galvanism  (25  elements)  to  external  popliteal  nerves  gives 
normal  and  jerky  contractions  on  both  sides.  Knee  tendon 
reflex  moderate  and  equal  on  both  sides." 

My  own  examinations  of  the  muscles,  made  both  before 
and  after  Dr.  Seguin's  tests,  agreed  with  the  above.  I 
also  found  a  normal  response  from  the  contracted  tibialis 
posticus — the  same  current  producing  contractions  on  either 
side,  the  extent  of  the  contraction  being  only  less  in  the 
affected  muscle,  and  this  was  due,  I  infer,  to  the  fact  that 
the  muscle  was  shortened. 

Charcot  describes  the  prominent  feature  presented  by 
this  case  as  pcri7ianent  contracture,  and  refers  to  it  as  being 
among  "  the  most  interesting  peculiarities  connected  with 
the  singular  manifestation  of  hysteria."*  He  presents 
several  cases  which  are  fully  detailed,  and  the  conclusions 
reached  are  very  valuable,  and  especially  so  to  us  in  our 
study  of  the  muscular  conditions,  as  applied  to  deformities. 
This   eminent   writer   says :  "  We   have   here   a   permanent 

"  On  Diseases  of  the  Nervous  System.  New  Sydenham  Edition,  1877. 
page  283. 


HYSTERICAL  JOINT  AFFECTIONS.  65 

contracture  in  the  rigorous  sense  of  the  word.  I  have  as- 
sured myself  that  it  is  in  nowise  modified  during  the 
profoundest  sleep  ;  in  the  day-time  there  are  no  alternations 
of  increase  or  remission.  The  slumber  alone  which  chloro- 
form produces  causes  it  to  disappear  if  the  intoxication 
produced  be  considerable.  *  *  *  The  nutrition  of  the 
muscles  has  not  sensibly  suffered  and  the  electrical  con- 
tractility remains  nearly  normal."  * 

The  diagnostic  value  of  purely  functional  atrophy,  of  the 
effect  of  the  anaesthesia  induced  by  chloroform  or  ether, 
and  the  electrical  test,  in  the  conditions  I  have  attempted 
to  describe,  are  again  made  evident  by  Charcot's  testimony. 
Indeed,  in  obscure  cases,  they  form  very  valuable  aids  to 
diagnosis.  It  does  not  answer,  as  we  have  seen,  to  assume 
because  a  patient  is  hysterical,  that  all  the  symptoms 
partake  of  this  character,  however  closely  the  obscure,  but 
real,  symptoms  may  resemble  the  nervous.  And  if,  in  a 
moderately  emotional  woman,  for  example,  a  condition  of 
hysterical  contracture  should  exist  at  the  hip-joint,  with 
other  symptoms  closely  resembling  hip  disease,  the  difificul- 
ties  of  diagnosis  can  be  very  easily  appreciated. 

Briefly,  then,  we  may  summarize  our  observations  upon 
the  muscular  conditions  in  joint  disease,  in  the  emotional 
contractions  and  in  the  hysterical  contractures,  as  follows : 

1st.  In  chronic  osteitis  of  the  articulations  there  exists 
a  specific  muscular  atrophy,  due  to  the  lesion  ;  an  invariable 
muscular  spasm — which  is  present  night  and  day,  and 
which,  while  not  modified  by  the  customary  doses  of 
chloral  or  opium,  disappears  completely  under  the  an- 
aesthesia induced  by  ether  or  chloroform.  There  is  present 
also  a  marked  reduction  of  the  faradic  contractility  of  the 
muscles  thus  affected, 

2d.     In  the  emotional  contractions  we  find  the  atrophy 
*0p.  cit.,  page  285. 


66  NEWTON  M.   SHAFFER. 

of  disuse  only, — a  variable  muscular  rigidity  which  disap- 
pears during  natural  sleep,  or  yields  to  opium  or  chloral — 
and  a  normal  faradic  contractility. 

3d.  In  the  hysterical  contracture  we  see  a  "permanent" 
muscular  rigidity,  which  like  the  muscular  spasm  of  chronic 
osteitis,  is  wholly  dissipated  by  the  profound  anaesthesia  of 
ether, — but  we  find  in  connection  with  it,  functional 
atrophy  only,  and  a  normal  faradic  reaction  of  the 
muscles. 

4th.  The  test  of  anaesthesia  induced  by  ether  or  chlo- 
roform, as  applied  to  the  differential  diagnosis  of  hysterical 
contraction  and  chronic  articular  osteitis  is  not  of  value, 
per  se,  though  some  eminent  authorities  have  stated  other- 
wise. Ether  or  chloroform  will  remove  the  "  permanent 
contracture  "  of  the  one,  and  suspend  the  reflex  spasm  of 
the  other.  The  elements  of  absolute  contracture, — such 
for  example,  as  are  met  with  in  congenital  talipes  or  torti- 
collis, and  intra-  or  extra-capsular  changes  (fibrous  anchy- 
losis, osteophytes,  etc.,)  being  eliminated,  we  should  bear 
in  mind,  in  making  our  examination  of  suspected  joints, 
under  ether,  Charcot's  valuable  deduction,  viz.,  "  that  the 
existence  of  a  spinal,  organic  lesion,  of  more  or  less  gravity 
will  be  placed  almost  beyond  a  doubt,  if  under  the  in- 
fluence of  sleep  induced  by  chloroform,  rigidity  of  the 
members  gives  way  slowly,  or  even  persists  to  any  marked 
extent."  * 

*  Op.  cit.,  p.  297. 


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